Comparison of Cadmium Zinc Telluride ECG-gated SPECT equilibrium radionuclide angiocardiography to magnetic resonance imaging to measure right ventricular volumes and ejection fraction in patients with cardiomyopathy.

AIMS: The objective of this study was to determine the accuracy of right ventricular function (RVF) assessed by Cadmium Zinc Telluride ECG-gated SPECT equilibrium radionuclide angiocardiography (CZT-ERNA). METHODS AND RESULTS: Twenty-one consecutive patients with cardiomyopathy (aged 54 ± 19 years; 62% male) were included. RV ejection fraction (EF) and volumes were analyzed by CZT-ERNA and compared with values obtained by cardiac magnetic resonance imaging (CMR). Mean values were not different between CZT-ERNA and MRI for RVEF (48.1 ± 10.4% vs 50.8 ± 10.0%; P = .23). Significant correlations (P < .0001) were observed between CZT-ERNA and MRI for RVEF, RV end-diastolic volume, and end-systolic volume (r = 0.81, r = 0.93, and r = 0.96, respectively). Bland-Altman analysis showed a mean difference (bias) between CZT-ERNA and MRI for RVEF of -2.69% (95% CI - 5.35 to - 0.42) with good agreement between the 2 techniques (limits of agreement, -14.3 to 8.99). Intraobserver and interobserver reproducibility of RVF measured by CZT-ERNA was high. CONCLUSION: CZT-ERNA provides accurate, reproducible assessment of RVF and appears as a good alternative to cardiac magnetic resonance for the evaluation of the magnitude of RVF in patients with cardiomyopathy.

De Novo Malignancies Screening After Liver Transplantation for Alcoholic Liver Disease: A Comparative Opportunistic Study.

Patients having received a liver transplantation (LT) for alcoholic liver disease (ALD) have a high risk of de novo malignancies, especially in the upper aerodigestive tract and lungs due to their smoking and alcohol history. The aim of this retrospective study was to compare a group of patients transplanted for ALD who continue to smoke and who were included in an intensive screening program for tobacco-related cancers implemented at the Grenoble University Hospital and a group of similar patients followed according to usual practice (chest computed tomography [CT] scan every 5 years) at the Edouard Herriot Hospital in Lyon. The intensive screening program consisted of an annual checkup, including a clinical examination by an otorhinolaryngologist, a chest CT scan, and an upper digestive endoscopy. A total of 147 patients were included: 71 patients in Grenoble and 76 patients in Lyon. The cumulative incidence of a first tobacco-related cancer was 12.3% at 3 years, 20.6% at 5 years, 42.6% at 10 years, and 64.0% at 15 years. A curative treatment was possible in 80.0% of the patients in Grenoble versus 57.9% in Lyon (P = 0.068). The rates of curative treatment were 63.6% versus 26.3% (P = 0.062) for lung cancers, 100.0% versus 87.5% (P = 0.498) for lip-mouth-pharynx and larynx cancers, and 66.7% versus 100.0% (P = 1) for esophageal cancers, respectively. In addition, for lung cancers, regardless of study group, 68.7% received a curative treatment when the diagnosis was made by CT scan screening versus 14.3% when it was made because of symptoms (P = 0.008). In conclusion, our study strongly confirms the high rate of tobacco-related de novo malignancies in LT patients for ALD and suggests that the screening of lung cancer by annual chest CT scan could significantly increase the rate of curative treatment.

Usual interstitial pneumonia end-stage features from explants with radiologic and pathological correlations.

Idiopathic pulmonary fibrosis (IPF) is the most frequent and severe idiopathic interstitial pneumonia, with typical high-resolution computed tomography (HRCT) features and histologic pattern of usual interstitial pneumonia (UIP); its main differential diagnosis is fibrotic nonspecific interstitial pneumonia (F-NSIP). Usual interstitial pneumonia was mainly described from lung biopsies, and little is known on explants. Twenty-two UIP/IPF explants were analyzed histologically and compared with previous open lung biopsies (OLBs; n = 11) and HRCT (n = 19), when available. Temporospatial heterogeneity and subpleural and paraseptal fibrosis were similarly found in UIP/IPF explants and OLB (91%-95%). Fibroblastic foci were found in 82% of OLBs and 100% of explants, with a higher mean score in explants (P = .023). Honeycombing was present in 64% of OLBs and 95% of explants, with a higher mean score in explants (P = .005). Almost 60% of UIP/IPF explants showed NSIP areas and 41% peribronchiolar fibrosis; inflammation, bronchiolar metaplasia, and vascular changes were more frequent in UIP/IPF explants; and Desquamative Interstitial Pneumonia (DIP)-like areas were not common (18%-27%). Numerous large airspace enlargements with fibrosis were frequent in UIP/IPF explants (59%). On HRCT, honeycombing was observed in 95% of the cases and ground-glass opacities in 53%, correlating with NSIP areas or acute exacerbation at histology. Six patients had combined IPF and emphysema. Lesions were more severe in UIP/IPF explants, reflecting the worsening of the disease. Usual interstitial pneumonia/IPF explants more frequently presented with confounding lesions such as NSIP areas, peribronchiolar fibrosis, and airspace enlargements with fibrosis sometimes associated with emphysema.

ECG-gated computed tomography to assess pulmonary capillary wedge pressure in pulmonary hypertension.

OBJECTIVE: We propose a non-invasive method for diagnosing post-capillary pulmonary hypertension (PH group 2). We evaluated pulmonary capillary wedge pressure (PCWP) by studying the left atrium (LA) on thoracic ECG-gated CT compared with right heart catheterisation (RHC). METHODS: We retrospectively studied 54 patients with suspected PH or followed for PH who underwent thoracic ECG-gated CT and RHC within 15 days. The diagnostic accuracy of CT morphological and functional data of the LA for the detection of PCWP >15 mmHg, evaluated by two independent readers, was assessed using correlation and receiver-operating characteristic (ROC) analysis. RESULTS: Interobserver agreement was high (r = 0.97-0.99). Correlations were found between PCWP and the morphological criteria of the LA such as anteroposterior diameter at 0 % of the R-R interval (r = 0.70, P ≤ 0.001) as well as at 40 % (r = 0.69, P ≤ 0.001). ROC curves constructed with a threshold value of PCWP > 15 mmHg showed an area under the curve between 0.88 and 0.91. Significant correlations were found between PCWP and functional criteria of the LA, including distensibility (r = -0.49, P ≤ 0.001) and ejection fraction (r = -0.58, P ≤ 0.001). CONCLUSION: Thoracic ECG-gated CT in a PH workup helps distinguish between pre- and post-capillary PH. KEY POINTS: • Computed tomography may help differentiate the various types of pulmonary hypertension (PH). • Post-capillary PH group 2 is due to left heart disease. • Right heart catheterisation is used to separate pre- and post-capillary PH. • Left atrium anteroposterior diameter measured on CT is of value. • ECG-gated CT helps clinicians to assess patients with PH non-invasively.

Prediction of lobar collateral ventilation in 25 patients with severe emphysema by fissure analysis with CT.

OBJECTIVE: Reducing pulmonary volume through implantation of endobronchial valves is a major interest to improve exercise tolerance and survival in patients with severe emphysema. The primary aim of this study was to evaluate how well CT-determined fissure integrity predicts interlobar collateral ventilation. The secondary objective was to show whether there is a relationship between the size of fissural defects and the presence of collateral ventilation. MATERIALS AND METHODS: Thirty patients with heterogeneous emphysema (postbronchodilator forced expiratory volume in 1 second [FEV1] = 20-50% predicted and > 50% of emphysema in a lobe) underwent collateral ventilation measurements with a catheter through an occlusive balloon within this target lobe during flexible endoscopy. Two senior thoracic radiologists studied the fissures on thoracic high-resolution CT. RESULTS: Collateral ventilation was successfully measured in 37 target lobes in 25 patients. The fissures surrounding the 37 target lobes were evaluated on CT. For the detection of collateral ventilation, the presence of a fissural defect on CT has a sensitivity, specificity, positive predictive value, and negative predictive value of 95%, 44%, 69%, and 88%, respectively. There was a statistically significant difference in the area of the defect between patients with collateral ventilation and those without collateral ventilation (p = 0.04). CONCLUSION: Analysis of pulmonary fissures using CT is useful before endoscopic volume reduction because results are well correlated to endoscopic measurements of collateral ventilation. Further study with clinical outcomes is mandatory to determine if and when one test or the other or both should be used in patient selection.

Case reports: iatrogenic bronchial rupture following the use of endotracheal tube introducers.

PURPOSE: Endotracheal tube introducers are often used in difficult tracheal intubations, but they are rarely deemed responsible for airway injuries. There have been only a few reports of severe complications, such as pharyngeal perforation, mainstem bronchus bleeding, perforation of the tracheal mucosa, and tracheal abrasion associated with hemopneumothorax. Using a computed tomography (CT) scan, we illustrate two cases of non-severe airway injuries related to endotracheal tube introducers. CLINICAL FEATURES: We present two cases of distal bronchial lacerations caused by introducers. The first occurrence was caused by a Muallem ET Tube Stylet (METTS) in a patient who underwent surgery for a total thyroidectomy and presented hemoptysis at suction after tracheal intubation. The second occurrence was caused by an Eschmann® Tracheal Tube Introducer (gum elastic bougie) in a patient whose trachea was intubated before a radiofrequency ablation of a single lung metastasis. There was evidence of blood on the tip of the bougie after withdrawal. In both cases, a CT scan showed a post-traumatic bronchial laceration with an acquired bronchial ectasia surrounded by ground-glass opacity due to alveolar hemorrhage. The patients had no other clinical complications, and bronchial lesions resolved spontaneously at control CT scan. CONCLUSION: These two cases show that airway damage related to endotracheal tube introducers may not be exceptional. It is not unusual to have some blood on an airway management device, and the rate and severity of these lesions are unknown. However, damage to the airway can be avoided by adapting preventive techniques during tracheal intubation.

Pulmonary artery and right ventricle assessment in pulmonary hypertension: correlation between functional parameters of ECG-gated CT and right-side heart catheterization.

BACKGROUND: Right ventricular function predicts outcome in patients with pulmonary hypertension (PH). Therefore accurate assessment of right ventricular function is essential to graduate severity, assess follow-up, and response to therapy. PURPOSE: To evaluate whether PH severity could be assessed using electrocardiography-gated CT (ECG-gated CT) functional parameters. A further objective was to evaluate cardiac output (CO) using two ECG-gated CT methods: the reference Simpson technique and the fully automatic technique generated by commercially available cardiac software. MATERIAL AND METHODS: Our institutional review board approved this study; patient consent was not required. Twenty-seven patients who had undergone ECG-gated CT and right heart catheterization (RHC) were included. Two independent observers measured pulmonary artery (PA) diameter, PA distensibility, aorta diameter, right ventricular cardiac output (CT-RVCO) and right ventricular ejection fraction (CT-RVEF) with automatic and Simpson techniques on ECG-gated CT. RHC-CO and mean pulmonary arterial pressure (mPAP) were measured on RHC. Relationship between ECG-gated CT and RHC measurements was tested with linear regression analysis. RESULTS: Inter-observer agreement was good for all measurements (r > 0.7) except for CT-RVCO calculated with Simpson's technique (r = 0.63). Pulmonary artery (PA) distensibility was significantly correlated to mPAP (r = -0.426, P = 0.027). CT-RVEF was correlated with mPAP only when issued from Simpson technique (r = -0.417, P = 0.034). CT-RVEF was not significantly correlated to RHC-CO (P > 0.2). CT-RVCO measured with Simpson technique (r = 0.487, P = 0.010) and automatic segmentation (r = 0.549, P = 0.005) correlated equally with RHC-CO. CONCLUSION: CT-RVEF and CT-RVCO measured on ECG-gated CT are significantly correlated, respectively, to mPAP and RHC-CO in this population with severe reduction of the right ventricular ejection fraction and could be useful for evaluating and following patients with PH.

Multimodal Imaging to Understand Left Ventricular Systolic Dysfunction in a Patient With Sepsis-Related Myocardial Calcification.

A 52-year-old man with acute peritonitis developed severely decreased left ventricular (LV) ejection fraction. Multimodal imaging allowed the diagnosis of sepsis-related myocardial calcification. Moreover, 2-dimensional speckle tracking echocardiography allowed a better understanding of LV dysfunction and confirmed the hypothesis that regional LV dysfunction is in accordance with the localization of calcifications. (Level of Difficulty: Intermediate.).

Prognosis of Coronary Atherosclerotic Burden in Non-Ischemic Dilated Cardiomyopathies.

BACKGROUND: Atherosclerosis is associated with a worse prognosis in many diseases such as ischemic cardiomyopathy, but its impact in non-ischemic dilated cardiomyopathy (dCMP) is lesser known. Our aim was to study the prognostic impact of coronary atherosclerotic burden (CAB) in patients with dCMP. METHODS: Consecutive patients with dCMP and left ventricular (LV) dysfunction diagnosed by concomitant analysis of invasive coronary angiography (ICA) and CMR imaging were identified from registry-database. CAB was measured by Gensini score. The primary composite endpoint was the occurrence of major adverse cardiovascular events (MACE) defined as cardiovascular (CV) mortality, non-fatal MI and unplanned myocardial revascularization. The results of 139 patients constituting the prospective study population (mean age 59.4 ± 14.7 years old, 74% male), average LV ejection fraction was 31.1 ± 11.02%, median Gensini score was 0 (0-3), and mid-wall late gadolinium enhancement (LGE) was the most frequent LGE pattern (42%). Over a median follow-up of 2.8 years, 9% of patients presented MACE. Patients with MACE had significantly higher CAB compared to those who were free of events (0 (0-3) vs. 3.75 (2-15), p < 0.0001). CAB remained the significant predictor of MACE on multivariate logistic analysis (OR: 1.12, CI: 1.01-1.23, p = 0.02). CONCLUSION: High CAB may be a new prognostic factor in dCMP patients.

Percutaneous CT-guided biopsy of lytic bone lesions in patients clinically suspected of lung cancer: Diagnostic performances for pathological diagnosis and molecular testing.

OBJECTIVES: Bone is a common location for lung cancer metastasis. Clinicians are often reluctant to biopsy bone metastases, as they are known to require a decalcification process that damages nucleic acids, which makes it incompatible with molecular testing. We performed this study to assess the diagnostic performance of histopathology and molecular testing of computed tomography (CT)-guided percutaneous bone biopsies of lytic bone lesions during the initial assessment or during the progression of lung cancer. MATERIALS AND METHODS: This retrospective study included all patients suspected of having or known to have primary lung cancer and CT-guided percutaneous bone biopsies of lytic bone from January 2010 to June 2017. The main judgment criterion was the diagnostic performance of the pathological analysis. Secondary endpoints were the diagnostic performance of molecular testing and incidence of complications. RESULTS: Fifty patients were included. The yield of CT-guided percutaneous bone biopsies for pathological analysis was 100 %, allowing for a diagnosis of certainty in all cases. The percentage of tumor cells in samples was higher than the 20 % threshold in 83.9 % of cases. The yield of molecular analysis was 94.6 %. A mutation was found in 60 % of cases; most frequently in KRAS (Kirsten rat sarcoma viral oncogene homolog) (28.6 %) and EGFR (epidermal growth factor receptor) (14.3 %). The complication rate was 2 %, i.e. a minor undrained pneumothorax. CONCLUSION: CT-guided percutaneous biopsies of lytic bone is associated with a very low complication rate and high diagnostic performance for histopathology and mutation testing.

Multi-detector CT evaluation in patients suspected of tracheobronchomalacia: comparison of end-expiratory with dynamic expiratory volumetric acquisitions.

PURPOSE: The aim of this study was to compare dynamic expiratory imaging and end-expiratory imaging using multi-detector CT (MDCT) of the central airways in patients suspected of tracheobronchomalacia (TBM). METHODS: This study had local ethical committee approval. Seventy patients suspected of TBM were prospectively included. All patients underwent evaluation of central airways by three different low-dose MDCT acquisitions: end inspiration, end expiration, and dynamic expiration. Degree of airway collapse was measured by calculating the percentage change in the area and diameter of the airways between inspiratory and the two expiratory techniques at three levels of the trachea and in the sagittal diameter of the right and left main bronchi. Three threshold levels of percentage reduction in diameter or area (30%, 50%, and 70%) for defining TBM were evaluated. RESULTS: In the entire population, the mean percentage of airway collapse was significantly greater with dynamic expiratory imaging than with the end-expiratory imaging at three different levels: lower thoracic trachea (26% vs. 16.6%, p<0.009), right (25.2% vs. 14%, p<0.01) and left main (24.7% vs. 13.3%, p<0.01) bronchus. Whatever the threshold value for defining TBM, dynamic expiratory imaging always resulted in diagnosing TBM in more patients than end-expiratory imaging. CONCLUSIONS: Dynamic expiratory imaging shows a significantly greater degree and a significantly greater extent of airway collapse than standard end-expiratory imaging in patients suspected of TBM. Further evaluation of the clinical relevance of such findings is warranted.

CT-guided biopsy of nonresolving focal air space consolidation.

OBJECTIVES: To evaluate the diagnostic accuracy of percutaneous computed tomography (CT)-guided coaxial core needle biopsy in patients with nonresolving pulmonary focal air space consolidations and negative fiberoptic bronchoscopy results. METHODS: From 1997 to 2005, 23 patients (11 woman, 12 men; age range, 45 to 81 y; mean age, 66 y) presenting with nonresolving pneumonia persisting more than 8 weeks (mean, 22 wk; range, 8 to 40 wk) with negative fiberscopic results, underwent coaxial percutaneous biopsy using an automated core needle (18-gauge) under CT guidance. Histologic and bacteriologic evaluations were obtained. The final diagnosis was confirmed by surgical pathology, culture results, or clinical follow-up. RESULTS: Specimens adequate for histopathologic evaluations were obtained in 20 (87%) cases. Final diagnoses were lung cancer (n=15) and benign diseases (infectious pneumonia, 3; lipoid pneumonia, 1; Erdheim Chester disease: 1; and nonspecific chronic pneumonia, 3). Diagnostic yield of core needle biopsy was 78% (18 of 23). The sensitivity and specificity for malignancy were 87% and 100%, respectively. Immediate pneumothorax was present in 11 patients of cases, but only 2 patients required pleural drainage. DISCUSSION: CT-guided lung biopsy using a core needle biopsy provides a high degree of diagnostic accuracy and allows specific characterization of nonresolving pulmonary focal air space consolidation.

Evaluation of Imaging Strategy to Optimize and Improve Outcome of Transcatheter Aortic Valvular Implantation.

Cardiac computed tomography (CT) provides additional information with ultrasound in the transcatheter heart valve (THV) size selection. However, the influence of these incremental data on outcomes has not been evaluated in a randomized study. A single-center prospective, randomized, and open study was performed. Patients referred for transfemoral transcatheter aortic valve implantation with a balloon-expandable endoprothesis were included. THV size selection was performed using either transthoracic and transesophageal echocardiography data (control group) or ultrasound and CT results (CT group). The primary composite end point included the occurrence of stroke, major vascular complications, and moderate or severe paravalvular aortic regurgitation (PAR) at 1 year. Fifty patients (n = 25 in the control and CT groups) were enrolled. The primary composite end point occurred in 40% and 8% of patients from the control and CT groups, respectively (p = 0.008). The Kaplan-Meier analysis revealed a pejorative association with not performing the CT (p = 0.007). A decrease in the occurrence of PAR was observed in the CT group compared with the control group (PAR 28% vs 4%, p = 0.04; major vascular complications 12% vs 4%, p = 0.6; all-cause death 16% vs. 4%, p = 0.34; no stroke). In conclusion, the use of cardiac CT in addition to ultrasound data in THV size selection reduced the long-term occurrence of cardiovascular events.

Differentiating pre- and minimally invasive from invasive adenocarcinoma using CT-features in persistent pulmonary part-solid nodules in Caucasian patients.

OBJECTIVE: To retrospectively investigate the diagnostic value of pre-operative CT-features between pre/minimally invasive and invasive lesions in part-solid persistent pulmonary ground glass nodules in a Caucasian population. MATERIALS AND METHODS: Retrospective review of two pre-operative CTs for 31 nodules in 30 patients. There were 10 adenocarcinomas in situ, 1 minimally invasive adenocarcinoma, 20 invasive adenocarcinomas. We analyzed the correlation between histopathology and the following CT-features: maximal axial diameter, maximal orthogonal axial diameter, height, density, size of solid component, air bronchogram, pleural retraction, nodule mass, disappearance rate and their evolution during follow-up. RESULTS: In univariate analysis, invasive adenocarcinomas had a higher maximal height, density, solid component size, mass, a lower disappearance rate and presented more often with pleural retraction (p<0.05). After logistic regression performed with the uncorrelated parameters using a method of selection of variables, only the size of solid component remained significant, with 100% sensitivity for invasive adenocarcinoma when larger than 5mm. CONCLUSION: Preoperative CT-features can help differentiating in situ and minimally invasive adenocarcinomas from invasive adenocarcinomas in Caucasian patients. A solid component larger than 5mm in diameter had 100% sensitivity for the diagnosis of invasive adenocarcinoma.