RESUMO
Left atrial thrombi are a significant cause of cardioembolic morbidity and mortality. Transesophageal echocardiography is the preferred method for complete visualization of atrial thrombi, and has a sensitivity and specificity of up to 100% and 99%, respectively. Cardiac magnetic resonance imaging has been shown to be useful in identifying tissue characteristics that may aid in differentiating between atrial myxoma and thrombi. This is an unusual case of a large, free-floating atrial thrombus with a cystic appearance that was surgically removed. The echocardiographic appearance of the cystic atrial mass led to the consideration of another potential etiology for a cardiac mass, namely, atrial myxoma. Histopathologic analyses of the mass led to the final diagnosis of an atrial thrombus.
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OBJECTIVES: To examine relationships between severity of echocardiography (echo) -evidenced diastolic dysfunction (DD) and volumetric filling by automated processing of routine cine cardiovascular magnetic resonance (CMR). BACKGROUND: Cine-CMR provides high-resolution assessment of left ventricular (LV) chamber volumes. Automated segmentation (LV-METRIC) yields LV filling curves by segmenting all short-axis images across all temporal phases. This study used cine-CMR to assess filling changes that occur with progressive DD. METHODS: 115 post-MI patients underwent CMR and echo within 1 day. LV-METRIC yielded multiple diastolic indices - E:A ratio, peak filling rate (PFR), time to peak filling rate (TPFR), and diastolic volume recovery (DVR80 - proportion of diastole required to recover 80% stroke volume). Echo was the reference for DD. RESULTS: LV-METRIC successfully generated LV filling curves in all patients. CMR indices were reproducible (< or = 1% inter-reader differences) and required minimal processing time (175 +/- 34 images/exam, 2:09 +/- 0:51 minutes). CMR E:A ratio decreased with grade 1 and increased with grades 2-3 DD. Diastolic filling intervals, measured by DVR80 or TPFR, prolonged with grade 1 and shortened with grade 3 DD, paralleling echo deceleration time (p < 0.001). PFR by CMR increased with DD grade, similar to E/e' (p < 0.001). Prolonged DVR80 identified 71% of patients with echo-evidenced grade 1 but no patients with grade 3 DD, and stroke-volume adjusted PFR identified 67% with grade 3 but none with grade 1 DD (matched specificity = 83%). The combination of DVR80 and PFR identified 53% of patients with grade 2 DD. Prolonged DVR80 was associated with grade 1 (OR 2.79, CI 1.65-4.05, p = 0.001) with a similar trend for grade 2 (OR 1.35, CI 0.98-1.74, p = 0.06), whereas high PFR was associated with grade 3 (OR 1.14, CI 1.02-1.25, p = 0.02) DD. CONCLUSIONS: Automated cine-CMR segmentation can discern LV filling changes that occur with increasing severity of echo-evidenced DD. Impaired relaxation is associated with prolonged filling intervals whereas restrictive filling is characterized by increased filling rates.
Assuntos
Imagem Cinética por Ressonância Magnética , Infarto do Miocárdio/complicações , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologia , Idoso , Automação , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Índice de Gravidade de Doença , Disfunção Ventricular Esquerda/etiologiaRESUMO
BACKGROUND: Cardiac power output (CPO) is a novel hemodynamic measurement that represents cardiac pumping ability. The prognostic value of CPO in a broad spectrum of patients with acute cardiac disease undergoing pulmonary artery catheterization (PAC) has not been examined. METHODS: Consecutive patients with a primary cardiac diagnosis who were undergoing PAC in a single coronary care unit were included. The relationship between initial CPO [(mean arterial pressure x cardiac output [CO])/451] and inhospital mortality was evaluated. CPO was analyzed both as a dichotomous variable (using a cutoff value previously established among patients with cardiogenic shock) and as a continuous variable. RESULTS: Data were available for 349 patients. The mean CPO was 0.88 +/- 0.37 W. The inhospital mortality rate was significantly higher among patients with a CPO < or = 0.53 W (n = 53) compared with those with a CPO > 0.53 W (n = 296) (49% vs 20%, P < .001). In separate multivariate analyses, both CPO and CO were associated with inhospital mortality. However, when both terms were included simultaneously, CPO remained strongly associated with mortality (odds ratio 0.63, 95% CI 0.43-0.91, P = .01), whereas CO did not (odds ratio 1.05, 95% CI 0.75-1.48, P = .78). CONCLUSIONS: Cardiac power output is a strong, independent predictor of inhospital mortality in a broad spectrum of patients with primary cardiac disease undergoing PAC.
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Débito Cardíaco , Cardiopatias/mortalidade , Cardiopatias/fisiopatologia , Doença Aguda , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Análise de SobrevidaRESUMO
Coronary computed tomography angiography (CTA) assessment of calcified or complex coronary lesions is frequently challenging. Transluminal attenuation gradient (TAG), defined as the linear regression coefficient between luminal attenuation and axial distance, has a potential to evaluate the degree of coronary stenosis. We examined the value of TAG in determining the stenosis severity on 64-slice coronary CTA. The value of TAG of 370 major coronary arteries was measured from 7,263 intervals of 5-mm length. Compared with coronary CTA and invasive coronary angiography, TAG decreased consistently and significantly with maximum stenosis severity on a per-vessel basis, from -1.91 ± 4.25 Hounsfield units/10 mm for diameter stenosis of 0% to 49% to -13.37 ± 9.81 Hounsfield units/10 mm for diameter stenosis of 100% (p < 0.0001). Adding TAG to the interpretation of coronary CTA improved diagnostic accuracy (p = 0.001), especially in vessels with calcified lesions (N = 127; net reclassification improvement 0.095; p = 0.046). TAG appears to be able to contribute to improved classification of coronary artery stenosis severity in coronary CTA, especially in severely calcified lesions.
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Angiografia Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Interpretação de Imagem Radiográfica Assistida por Computador , Tomografia Computadorizada por Raios X , Calcificação Vascular/diagnóstico por imagem , Idoso , Distribuição de Qui-Quadrado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , República da Coreia , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: For patients with thoracic aortic aneurysms (TAA), aortic size on imaging is widely used to guide clinical decision making. This study examined the impact of methodological variance on aortic quantification. METHODS: We studied enrollees in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. Aortic size on computed tomography was quantified by 2 linear methods; cross-sectional dimensions in axial (AX) and double oblique (DO) plane. Calculated area was compared to planimetry. Established cutoffs (area/height>10 cm2/m, diameter≥5 cm) for prophylactic TAA repair were used to compare surgical eligibility by each method. RESULTS: Fifty subjects were studied. Aortic size differed between AX and DO at all locations (p≤0.001), with magnitude greatest at the sinotubular junction (4.8±1.1 vs 4.0±1.0 cm, p<0.001). The difference between AX and DO correlated with aortic angular displacement (r=0.37, p<0.01), which was threefold larger at the sinotubular junction (37±12 degrees) than the ascending aorta (12±5 degrees; p<0.001). At all locations, aortic area calculated using DO yielded smaller differences with planimetry than AX (p<0.05). DO and planimetry yielded equal prevalence (24%) of subjects eligible for prophylactic TAA repair based on area-height cutoff, whereas AX prevalence was higher (44%; p=0.006). Using a linear cutoff, AX yielded over a twofold greater prevalence of surgically eligible subjects (56%) than did DO (24%; p<0.001). CONCLUSIONS: Established linear methods for aortic measurement yield different results that impact surgical eligibility. DO yielded improved agreement with planimetry and differed with AX in proportion to aortic geometric obliquity. Findings support DO measurements for imaging evaluation of subjects with TAA.
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Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica , Tomada de Decisões , Processamento de Imagem Assistida por Computador/métodos , Procedimentos Cirúrgicos Vasculares , Adulto , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Radiografia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
A cardiac thrombus provides a substrate for thromboembolic events. Delayed enhancement cardiac magnetic resonance imaging detects a thrombus based on avascular tissue properties, and has been shown to provide improved detection of a left ventricular thrombus, compared with anatomic imaging using echocardiography. We present a case of a young man with cerebrovascular stroke in whom delayed enhancement cardiac magnetic resonance provided incremental diagnostic utility for identification of a thrombus within both the left-sided and right-sided cardiac chambers.
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Trombose Coronária/patologia , Insuficiência Cardíaca/patologia , Acidente Vascular Cerebral/patologia , Adulto , Anticoagulantes/uso terapêutico , Trombose Coronária/complicações , Trombose Coronária/tratamento farmacológico , Diagnóstico Diferencial , Seguimentos , Insuficiência Cardíaca/complicações , Humanos , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Acidente Vascular Cerebral/complicações , Varfarina/uso terapêutico , Adulto JovemRESUMO
First-pass perfusion and delayed enhancement cardiac imaging have been shown to be feasible by cardiac CT. However, questions remain about its reliability, and ideal scanning parameters have yet to be fully established. In general, scar imaging with cardiac CT typically requires 2 scans, with first-pass perfusion information derived from the same data set used to visualize the coronary arteries. Reduced contrast enhancement on first-pass cardiac CT images represents reduced perfusion. Higher doses of contrast are required to perform viability imaging by cardiac CT. Approximately 10 minutes after contrast administration, viability information is obtained by performing a second (noncontrast) scan. In addition to the concepts of perfusion and viability imaging by cardiac CT, we review parameters such as scan timing, tube settings, contrast delivery, reconstruction, and postprocessing techniques, as well as the associated pitfalls and technical limitations in perfusion and viability imaging by cardiac CT.
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Angiografia Coronária/métodos , Infarto do Miocárdio/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Artefatos , Sobrevivência Celular , Meios de Contraste , HumanosRESUMO
The continued advancement of multidetector computed tomography (MDCT) has launched an exciting new method for myocardial viability imaging. This article aims to present data validating MDCT for viability imaging, to demonstrate MDCT's prognostic clinical value, and to delineate its potential clinical applications.
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Angiografia Coronária/métodos , Angiografia Coronária/tendências , Doença da Artéria Coronariana/diagnóstico por imagem , Miocárdio Atordoado/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/tendências , Disfunção Ventricular Esquerda/diagnóstico por imagem , Angiografia Coronária/instrumentação , Doença da Artéria Coronariana/complicações , Humanos , Miocárdio Atordoado/complicações , Intensificação de Imagem Radiográfica/métodos , Intensificação de Imagem Radiográfica/tendências , Tomografia Computadorizada por Raios X/instrumentação , Disfunção Ventricular Esquerda/complicaçõesRESUMO
Images of a case showing Gerbode defect are presented with transesophageal echo correlation.
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Insuficiência da Valva Aórtica/diagnóstico por imagem , Endocardite/diagnóstico por imagem , Defeitos dos Septos Cardíacos/diagnóstico por imagem , Infecções Estreptocócicas/diagnóstico por imagem , Insuficiência da Valva Aórtica/complicações , Endocardite/complicações , Feminino , Defeitos dos Septos Cardíacos/complicações , Humanos , Pessoa de Meia-Idade , Radiografia , Infecções Estreptocócicas/complicações , UltrassonografiaRESUMO
Paradoxical septal motion is commonly noted on echocardiography after coronary artery bypass grafting (CABG), but its mechanism is unclear. Cardiac magnetic resonance imaging was performed before and 3 months after CABG in 23 patients. On a mid-left ventricular short-axis cine image, the motion of myocardial landmarks during the cardiac cycle was ascertained relative to a stationary anterior reference point. Before CABG, the movement of the ventricular septum in systole was either posterior or neutral (median -2 mm) in 19 patients, whereas after CABG, the septum moved anteriorly in all 23 patients (+4 mm; p<0.001). (A positive sign indicates anterior motion in ventricular systole, and a negative sign denotes posterior motion.) The motion of the right ventricular free wall was reduced after CABG (-5 vs -3 mm; p=0.002), whereas anterior movement of the lateral left ventricular wall in systole increased (+4 vs +9 mm; p<0.001). There was a positive correlation between degree of anterior movement of the ventricular septum and right ventricular ejection fraction (r=0.47, p=0.023). In conclusion, after CABG, the entire left ventricle translocated anteriorly in systole. Despite preserved right ventricular function, there was restricted motion of the right ventricular free wall suggestive of postoperative adhesions. The pattern of movement observed offers a sound explanation for postoperative paradoxical septal motion.
Assuntos
Ponte de Artéria Coronária , Septos Cardíacos/fisiopatologia , Ventrículos do Coração/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste , Feminino , Gadolínio DTPA , Septos Cardíacos/cirurgia , Ventrículos do Coração/cirurgia , Humanos , Processamento de Imagem Assistida por Computador , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estatísticas não Paramétricas , SístoleRESUMO
OBJECTIVES: This study sought to evaluate the feasibility of using ultra-low-dose intra-arterial contrast injection for iliofemoral computed tomographic (CT) angiography to follow diagnostic cardiac catheterization. BACKGROUND: Cardiovascular interventions such as percutaneous aortic valve replacement require transfemoral delivery of large-bore intra-arterial catheters; therefore, pre-procedural assessment of aortoiliofemoral anatomy is important. CT angiography is ideal for this purpose but requires a large volume of intravenous contrast. METHODS: Consecutive patients requiring evaluation of aortoiliofemoral anatomy underwent conventional anteroposterior projection iliac angiography during cardiac catheterization. A pigtail catheter was left in situ in the infrarenal abdominal aorta, and patients were transferred to the CT suite. Subsequently, 10 to 15 ml of contrast diluted with normal saline was injected intra-arterially via the pigtail catheter while a spiral CT of the abdomen and pelvis was acquired. Conventional angiographic and CT images were analyzed independently to assess suitability for large-bore (7-mm-diameter)intra-arterial catheter access. RESULTS: Excellent CT image quality was achieved in 34 of 37 patients (92%). The mean contrast dose for CT was 12 +/- 2 ml. In 9 patients (24%), CT changed the assessment of femoral access feasibility. Furthermore, in another 7 patients (19%), unfavorable anatomy as shown by CT directed the avoidance of a particular side. Overall, CT findings altered the interventional approach in 16 patients (43%). There was no significant deterioration detected in renal function after coronary and CT angiography (estimated glomerular filtration rate 54.8 +/- 3.8 ml/min before 53.3 +/- 3.9 ml/min after, p = 0.55). CONCLUSIONS: High-quality aortoiliofemoral CT angiography can be obtained with a technical success rate of >90% using 10 to 15 ml of contrast injected via a catheter in the abdominal aorta, and offers an alternative to conventional X-ray or CT angiography with high-volume intravenous contrast injection.