CT evaluation of aberrant right subclavian artery: anatomy and clinical implications.

PurposeThe aim of the study was to perform CT angiography-based evaluation of aberrant right subclavian artery prevalence, anatomy, and its influence on clinical symptoms. METHODS: A total of 6833 patients who underwent 64-slice or dual-source CT angiography and those who revealed aberrant right subclavian artery underwent evaluation of its anatomy and were interviewed for the presence of clinical symptoms. RESULTS: Aberrant right subclavian artery was found in 32 (0.47%) patients consisting of 13 males and 19 females, with mean age of 60.8±13.4 years. Among the interviewed 30 (94%) patients, oesophageal compression was observed in 14 cases (47%) and tracheal compression in three cases (10%). None of the patients underwent surgery related to aberrant right subclavian artery. Dysphagia was the most common clinical symptom in nine cases (30%), and in those patients the median distance between aberrant right subclavian artery and trachea was lower (4 mm) than in individuals without dysphagia (7.5 mm) (p = 0.009). The median lumen area of the aberrant right subclavian artery at the level of oesophagus was higher in patients with dysphagia (208 mm2) compared with individuals without dysphagia (108 mm2) (p = 0.01). CONCLUSIONS: Aberrant right subclavian artery is a rare occurring abnormality in CT angiography. In the evaluated adult population, the most common symptom was dysphagia, which occurred in patients with decreased distance between aberrant right subclavian artery and trachea and increased lumen area of the aberrant artery at the level of compressed oesophagus.

Anomalous origin of the coronary artery from the wrong coronary sinus evaluated with computed tomography: "high-risk" anatomy and its clinical relevance.

OBJECTIVE: The aim of the study was to assess coronary arteries arising from the wrong coronary sinus, including CT-evaluated high-risk anatomic features, clinical symptoms and cardiac events during follow-up. METHODS: A total of 7,115 patients scheduled for 64-slice or dual-source cardiac CT were screened for the presence of isolated anomalous origin of the coronary artery from the wrong coronary sinus. RESULTS: Anomalous origin of the coronary artery was found in 54 (0.76 %) patients (29 men, 25 women, mean age 60.9 ± 11.6 years). Sixteen (30 %) patients with abnormal right coronary origin (ARCA) more commonly had a slit-like orifice (15 vs. 3; p < 0.001), intramural course (15 vs. 3; p < 0.001) and interarterial course (11 vs. 0; p < 0.001) than 22 (41 %) and 13 (24 %) individuals with abnormal circumflex artery (ALCx) and left coronary artery (ALCA) origin, respectively. Patients with ALCA presented less frequently with chest pain than subjects with ARCA and ALCx (25 vs. 3; p = 0.03). Patients with ARCA tended to show higher occurrence of cardiac events in the follow-up than individuals with ALCA and ALCx (5 vs. 4; p = NS). CONCLUSIONS: High-risk anatomy features are most common in patients with ARCA and these patients also have higher prevalence of chest pain and cardiac events in the follow-up than individuals with ALCA and ALCx. KEY POINTS: • Multislice computed tomography enables detection and evaluation of the coronary artery anomalies. • Anomalous anatomy of the coronary artery potentially influences the prevalence of adverse events. • Adverse events tend to be most common in anomalous right coronary arteries.

Relation between cardiac magnetic resonance-assessed interstitial fibrosis and diastolic dysfunction in heart failure due to dilated cardiomyopathy.

Background: Dilated cardiomyopathy (DCM) is distinguished by left ventricle (LV) dilation accompanied by systolic dysfunction. However, some studies suggested also a high prevalence of LV diastolic dysfunction (LVDD), similar to a general cohort of heart failure (HF) with reduced ejection fraction (LVEF). The bulk of evidence, mostly arising from basic studies, suggests a causative link between cardiac fibrosis (CF) and LVDD. However, still, there remains a scarcity of data on LVDD and CF. Therefore, the aim of the study was to investigate the association between CF and LVDD in DCM patients. Methods: The study population was composed of 102 DCM patients. Replacement CF was evaluated qualitatively (late gadolinium enhancement - LGE) and quantitively (LGE extent); interstitial cardiac fibrosis was assessed via extracellular volume (ECV). Based on echocardiography patients were divided into normal and elevated left atrial pressure (nLAP, eLAP) groups. Results: 42 % of patients had eLAP. They displayed higher troponin and NT-proBNP. Both groups did not differ in terms of LGE presence and extent; however, eLAP patients had larger ECV: 30.1 ± 5.6 % vs. 27.8 ± 3.9 %, p = 0.03. Moreover, ECV itself was found to be an independent predictor of LVDD (OR = 0.901; 95 %CI 0.810-0.999; p = 0.047; normalised for LVEF and RVOT diameter). Conclusions: More than two-in-five DCM patients had at least moderate LVDD. The mere presence or extent of replacement cardiac fibrosis is similar in patients with nLAP and eLAP. On the other hand, interstitial cardiac fibrosis is more pronounced in those with a higher grade of LVDD. ECV was found to be an independent predictor of LVDD in DCM.

[Right corbnary artery aneurysms in patient with suspicion of heart tumor]. / Tetniaki prawej tetnicy wiencowej u pacjenta z podejrzeniem guza serca.

Coronary arteries aneurysms are rare occurring abnormalities, concerning mostly right coronary artery. We present a case of a 60-year old man who underwent magnetic resonance (MRI) due to suspicion of cardiac tumor in the previously performed echocardiography. MRI examination suggested right coronary artery aneurysm. The diagnosis was confirmed in the performed computed tomography (CT) and additionally coronary aneurysm of distal part of right coronary artery was visualized.

[Cystic lesion in the topography of occluded aortocoronary saphenous vein bypass]. / Zmiana torbielowata w topografii niedroinego, zylnego pomostu aortalno-wiencowego.

Article presents a case of a 66-year old manwith a pericardial cyst, localized in tlhe topography of an occluded aorto-ccoronary saphenous vein graft. The lesion was revealed in computed tomogrnaphy and also evaluated in the subsequently performed magnetic resonance.

[Anomalous right upper pulmonary venous drainage into the superior vena cava with coexistence sinus venosus atrial septal defect (ASD)]. / Nieprawidlowy splyw zyly plucnej górnej prawej do zyly glównej górnej wraz ze wspólistniejacym ubytkiem w przegrodzie miedzyprzedsionkowej o typie zatoki zylnej (ASD).

Article presents a case of a 71-year old woman with pulmonary right upper venous drainage into the superior vena cava and with coexistence sinus venous type Atrial Septal Defect (ASD) which was revealed as interesting finding in multislices computed tomography angiography during estimation of coronary arteries.

Does magnetic resonance spectroscopy identify patients with minimal hepatic encephalopathy?

BACKGROUND AND PURPOSE: The results of a few studies suggest that magnetic resonance spectroscopy of the brain could allow detection of minimal hepatic encephalopathy. The goal of this study was to assess the ability of magnetic resonance spectroscopy to differentiate between cirrhotic patients with and without minimal hepatic encephalopathy. MATERIAL AND METHODS: Localized magnetic resonance spectroscopy was performed in the basal ganglia, occipital gray matter and frontal white matter in 46 patients with liver cirrhosis without overt encephalopathy and in 45 controls. Neurological and neuropsychological examination was performed in each participant. RESULTS: The patients with liver cirrhosis had a decreased ratio of myoinositol to creatine in occipital gray matter and frontal white matter (mean: 0.17 ± 0.05 vs. 0.20 ± 0.04, p = 0.01 and 0.15 ± 0.05 vs. 0.19 ± 0.04, p < 0.01, respectively) and a decreased ratio of choline to creatine in occipital gray matter (mean: 0.32 ± 0.07 vs. 0.36 ± 0.08, p = 0.03). Minimal hepatic encephalopathy was diagnosed in 7 patients. Metabolite ratios did not differ significantly between patients with and without minimal hepatic encephalopathy. Metabolite ratios did not differ significantly between patients with Child-Pugh A and those with Child-Pugh B. CONCLUSIONS: Magnetic resonance spectroscopy does not allow accurate diagnosis of minimal hepatic encephalopathy. A similar profile of metabolites in the brain is observed in cirrhotic patients without cognitive impairment.

Diffusion-tensor magnetic resonance imaging of the human heart in health and in acute myocardial infarction using diffusion-weighted echo-planar imaging technique with spin-echo signals.

Introduction: Originally thought unsuitable due to proneness to myocardial motion and susceptibility artefacts, spin-echo echo planar imaging (SE-EPI) has gained attention for the cardiac diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) offering higher SNR and lower achievable echo time (TE). Aim: The application of DTI for patients with acute myocardial infarction (AMI) using our methodology developed on the basis of the SE-EPI sequence. Material and methods: Twelve patients with AMI and six healthy controls were enrolled in the preliminary DTI study within the CIRCULATE STRATEGMED 2 project. Our method relied on a pilot ECG-triggered DTI examination, based on which the initial evaluation was possible and allowed proper manipulation of TE (64/47 ms for patients/control), repetition time (TR) and ECG trigger delay in the consecutive DTI. Results: The study demonstrated that by using our algorithm it was possible to obtain DWI images showing infarct zones identified on T1-weighted images with late gadolinium-enhancement (LGE) with division into subtle and severe damage. Quantitative DTI showed increased mean diffusivity (MD) and decreased fractional anisotropy (FA) in the infarct compared to remote tissue. The application of B-matrix spatial distribution (BSD) calibration allowed the improvement of FA. Conclusions: Our algorithm is suitable for qualitative assessment of infarction zones with different severity. The analysis of the quantitative DTI showed that despite the lack of motion compensation blocks in the applied SE-EPI sequence, it was possible to approach the diffusion tensor parameter values reported for the myocardium.

Acute myocardial infarction reparation/regeneration strategy using Wharton's jelly multipotent stem cells as an 'unlimited' therapeutic agent: 3-year outcomes in a pilot cohort of the CIRCULATE-AMI trial.

Introduction: CIRCULATE-AMI (NCT03404063), a cardiac magnetic resonance imaging (cMRI) infarct size-reduction-powered double-blind randomized controlled trial (RCT) of standardized Wharton jelly multipotent stem cells (WJMSCs, CardioCell Investigational Medical Product) vs. placebo (2 : 1) transcoronary transfer on acute myocardial infarction (AMI) day ~5-7, is preceded by safety and feasibility evaluation in a pilot study cohort (CIRCULATE-AMI PSC). Aim: To evaluate WJMSC transplantation safety and evolution of left ventricular (LV) remodeling in CIRCULATE-AMI PSC. Material and methods: In 10 consecutive patients (32-65 years, peak CK-MB 533 ±89 U/l, cMRI-LVEF 40.3 ±2.7%, cMRI-infarct size 20.1 ±2.8%), 30 × 106 WJMSCs were administered using a novel cell delivery-dedicated, coronary-non-occlusive method (CIRCULATE catheter). Other treatment was guideline-based. Results: WJMSC transfer was safe and occurred in the absence of coronary (TIMI-3 in all) or myocardial (corrected TIMI frame count (cTFC) 45 ±8 vs. 44 ±9, p = 0.51) flow deterioration or troponin elevation. By 3 years, 1 patient died from a new, non-index territory AMI; there were no other major adverse cardiovascular and cerebrovascular events (MACCE) and no adverse events that might be related to WJMSCs. cMRI infarct size was reduced from 33.2 ±7.6 g to 25.5 ±6.4 g at 1 year and 23.1 ±5.6 g at 3 years (p = 0.03 vs. baseline). cMRI, SPECT, and echo showed a consistent, statistically significant increase in LVEF at 6-12 months (41.9 ±2.6% vs. 51.0 ±3.3%, 36.0 ±3.9% vs. 44.9 ±5.0%, and 38.4 ±2.5% vs. 48.0 ±2.1% respectively, p < 0.01 for all); the effect was sustained at 3 years. Conclusions: CIRCULATE-AMI PSC data suggest that WJMSC transcoronary application ~5-7 days after large AMI in humans is feasible and safe and it may be associated with a durable LVEF improvement. CIRCULATE-AMI RCT will quantify the magnitude of LV adverse remodeling attenuation with CardioCell/placebo administration.

Multimodality assessment of cardiac involvement in Churg-Strauss syndrome patients in clinical remission.

BACKGROUND: Cardiac involvement in Churg-Strauss syndrome (CSS) is not uncommon, but its frequency varies widely and may depend on the activity of the disease. Therefore, the cardiac involvement in CSS patients in clinical remission was assessed in the present study. METHODS AND RESULTS: In 20 CSS patients in remission and 20 sex- and age-matched healthy controls, an ECG stress test, echocardiography, and 24-h ECG Holter monitoring were performed, together with cardiac magnetic resonance imaging (cMRI). Cardiac involvement was present in 90% (18/20) of CSS patients. Left ventricular ejection fraction (LVEF) was on average lower in the CSS group than in controls (P<0.05), with 7 patients showing systolic heart failure (LVEF <50%). cMRI changes included late gadolinium enhancement lesions in the LV in 89% of patients (17/19), present in all layers of the myocardium. Signs of ongoing inflammation (early gadolinium enhancement) and edema (T2-weighted imaging) were present in 6/19 patients. Holter monitoring revealed both supraventricular and ventricular arrhythmias more frequently in CSS patients when compared with controls (P<0.05). Absolute eosinophil count before the initiation of treatment was higher in rhythm disturbances (P<0.05), and inversely correlated with LV systolic function (rho -0.65). CONCLUSIONS: Heart involvement in CSS patients who are in clinical remission is very common. It is characterized not only by fibrosis, but also by an active inflammatory process. The latter finding might influence therapeutic decisions in CSS patients in full clinical remission.

Diffusion as a Natural Contrast in MR Imaging of Peripheral Artery Disease (PAD) Tissue Changes. A Case Study of the Clinical Application of DTI for a Patient with Chronic Calf Muscles Ischemia.

This paper reports a first application of diffusion tensor imaging with corrections by using the B-matrix spatial distribution method (BSD-DTI) for peripheral artery disease (PAD) detected in the changes of diffusion tensor parameters (DTPs). A 76-year-old male was diagnosed as having PAD, since he demonstrated in angiographic images of lower legs severe arterial stenosis and the presence of lateral and peripheral circulation and assigned to the double-blind RCT using mesenchymal stem cells (MSCs) or placebo for the regenerative treatment of implications of ischemic diseases. In order to indicate changes in diffusivity in calf muscles in comparison to a healthy control, a DTI methodology was developed. The main advantage of the applied protocol was decreased scanning time, which was achieved by reducing b-value and number of scans (to 1), while maintaining minimal number of diffusion gradient directions and high resolution. This was possible due to calibration via the BSD method, which reduced systematic errors and allowed quantitative analysis. In the course of PAD, diffusivities were elevated across the calf muscles in posterior compartment and lost their anisotropy. Different character was noticed for anterior compartment, in which diffusivities along and across muscles were decreased without a significant loss of anisotropy. After the intervention involving a series of injections, the improvement of DTPs and tractography was visible, but can be assigned neither to MSCs nor placebo before unblinding.

Lack of Relationship between Fibrosis-Related Biomarkers and Cardiac Magnetic Resonance-Assessed Replacement and Interstitial Fibrosis in Dilated Cardiomyopathy.

The relationship between circulating fibrosis-related molecules and magnetic resonance-assessed cardiac fibrosis in dilated cardiomyopathy (DCM) is poorly understood. To compare circulating biomarkers between DCM patients with high and low fibrosis burdens, we performed a prospective, single-center, observational study. The study population was composed of 100 DCM patients (87 male, mean age 45.2 ± 11.8 years, mean ejection fraction 29.7% ± 10.1%). Replacement fibrosis was quantified by means of late gadolinium enhancement (LGE), whereas interstitial fibrosis was assessed via extracellular volume (ECV). Plasma concentrations of cardiotrophin-1, growth differentiation factor-15, platelet-derived growth factor, procollagen I C-terminal propeptide, procollagen III N-terminal propeptide, and C-terminal telopeptide of type I collagen were measured. There were 44% patients with LGE and the median ECV was 27.7%. None of analyzed fibrosis serum biomarkers were associated with the LGE or ECV, whereas NT-proBNP was independently associated with both LGE and ECV, and troponin T was associated with ECV. None of the circulating fibrosis markers differentiated between DCM patients with and without replacement fibrosis, or patients stratified according to median ECV. However, cardiac-specific markers, such as NT-proBNP and hs-TnT, were associated with fibrosis. Levels of circulating markers of fibrosis seem to have no utility in the diagnosis and monitoring of cardiac fibrosis in DCM.

[Primary percutaneous coronary intervention with DES implantation after Bentall de Bono procedure; late in-stent restenosis after DES implantation]. / Pierwotna angioplastyka z implantacja stentuuwalniajacego lek po operacji Bentall De Bono;pózna restenoza w stencie uwalniajacym lek.

We report a case of acute coronary syndrome in a 58 year-old man with a history of double Bentall De Bono procedure (redo due to endocarditis). During the second operation, both main native coronary arteries were anastomosed end-to-end to aortic prosthesis using short vein graft insertions. Four months later the patient presented to the CCU with unstable angina. Computed tomography-scan suggested bilateral ostial stenoses. Percutaneous coronary intervention of the left proximal anastomosis was performed with DES. 14 months later the patient was treated with in-(DES) DES implantation.

[Use of magnetic resonance in the diagnostics of ischemic heart disease]. / Zastosowanie rezonansu magnetycznego w diagnostyce choroby niedokrwiennej serca.

The role of magnetic resonance imaging (MRI) as a diagnostic tool of coronary arteries disease has increased over the last years. Cardiac magnetic resonance (CMR) is a preferable tool in assessment of ventricular mass and function, presence and size of post infarct scaring and anomalies of coronary arteries. CMR becomes also a useful method in evaluation of myocardial viability. Examination with gadolinium dye allows for evaluation of myocardial perfusion and viability. The extent of the post infarct late enhancement zone has an important prognostic value in the recovery of the left ventricle function. Dobutamine, adenosine or dypirydamol stress CMR becomes a promising noninvasive diagnostic modality in detection of coronary artery disease. At present coronary arteries magnetic resonance angiography is being developed as well as CMR spectroscopy.

[Assessment of coronary artery stents in computed tomography: state of the art]. / Ocena stentów tetnic wiencowych w tomografii komputerowej: stan obecny.

Percutaneous coronary interventions (PCI) with stent implantation play an important role in the revascularization therapy of coronary artery disease. Introduction of drug eluting stents (DES) diminished problem of restenosis but brought several new major problems like i.e. late stent thrombosis. This makes bare metal stents (BMS) still popular choice for some patients. Coronary-artery-computed-tomography becomes useful device in the noninvasive diagnostics measure of restenosis after PCI. Development of 64-slice computed tomography (CT) enables the noninvasive imaging and evaluation of stents with diameter higher than 3,0 mm and detection of significant restenosis with a low number of false positive results. CT allows with high accuracy to exclude in-stent restenosis among patients with atypical angina, especially those localized in proximal segments of coronary arteries. Future development of CT is needful since evaluation of significant number of examinations remains difficult or impossible due to presence of artifacts.

Myocardial perfusion in hypertensive patients with normal coronary angiograms.

BACKGROUND: Pressure-induced left ventricular hypertrophy is one of the mechanisms responsible for an impaired coronary vasodilating capacity leading to myocardial ischemia and angina. The aim of the study was to investigate myocardial perfusion using cardiovascular magnetic resonance in patients with arterial hypertension and a history of chest pain and normal coronary angiography, and to estimate the influence of left ventricular hypertrophy on the parameters of myocardial perfusion. METHODS: The study included 102 patients (mean age 55.4 +/- 7.7 years) with well controlled hypertension and 12 healthy volunteers. In 96 patients, myocardial first-pass perfusion cardiovascular magnetic resonance both at rest and during an infusion of adenosine 140 microg/kg/min was performed. Semiquantitative perfusion analysis was performed by using the upslope of myocardial signal enhancement to derive the myocardial perfusion index and the myocardial perfusion reserve index. The study group was divided according to the presence of left ventricular hypertrophy in the cardiovascular magnetic resonance examination: group with left ventricular hypertrophy (n = 40) and without left ventricular hypertrophy (n = 56). RESULTS: Independent of the presence of left ventricular hypertrophy, there were significant differences in baseline myocardial perfusion index between hypertensive patients and controls (0.13 +/- 0.07 vs. 0.04 +/- 0.01; P < 0.001), and in stress myocardial perfusion index (hypertensive patients 0.21 +/- 0.10 vs. controls 0.09 +/- 0.03; P < 0.001). In hypertensive patients, the myocardial perfusion reserve index was reduced in the mid and apical portions of the left ventricle (1.71 +/- 1.1 vs. 2.52 +/- 0.83; P < 0.02). There was no significant correlation of myocardial perfusion reserve index with left ventricular mass or hypertrophy. CONCLUSION: In patients with mild or moderate hypertension and a history of chest pain with normal coronary angiography, there is regional myocardial perfusion reserve impairment that is independent of the presence of left ventricular hypertrophy and may be a reason for angina.

Applications of low-cost 3D printing in left atrial appendage closure using epicardial approaches - initial clinical experience.

INTRODUCTION: Left atrial appendage occlusion procedure (LAAO) became an alternative method for stroke prevention in atrial fibrillation (AF) patients with contraindication or intolerance for oral anticoagulation therapy. However, LAA anatomy is complex with several different types of LAA morphology. Therefore matching the correct size of a delivery device to LAA morphology is difficult. In such circumstances, the 3D-printed model of LAA closure may be useful for preoperative planning which increases the efficacy of LAAO procedure. MATERIAL AND METHODS: We report as a first 2 cases of LAA occlusion procedure using 2 different systems: thoracoscopic AtriClip and the LARIAT device in which a 3D printed LAA model was used in preoperative planning. RESULTS: In the first patient, preoperative measurements of 3D LAA model were performed using a dedicated selection guide for AtriClip device were comparable with the intraoperative examination. Left atrial appendage was closed epicardial using 40 mm size AtriClip. In second patients, LAA closure was performed completely percutaneously using LARIAT device. For better visualization of LAA shape on fluoroscopy and TEE examination, intraoperatively sterilized 3D LAA model was used during the procedure. In both cases, intraoperative TEE examination confirmed complete LAA closure with no leak. CONCLUSIONS: Left atrial appendage 3D model is a useful tool in preoperative planning of a left atrial appendage occlusion using epicardial approaches with thoracoscopic or percutaneous access using LARIAT device. The quality of low-cost 3D printed LAA model is sufficient in planning minimally invasive procedure.