Regional differences of fat depot attenuation using non-contrast, contrast-enhanced, and delayed-enhanced cardiac CT.

BACKGROUND: Regional fat density assessed by computed tomography (CT) has been suggested as a marker of perivascular adipose tissue inflammation. Dual energy CT (DECT) allows improved tissue characterization compared to conventional CT. PURPOSE: To explore whether DECT might aid regional fat density discrimination. MATERIAL AND METHODS: We included patients who had completed a non-enhanced cardiac CT scan, CT coronary angiography (CTCA), and a delayed enhancement CT. Attenuation levels (Hounsfield units [HU]) were assessed at the epicardial, paracardial, visceral, and subcutaneous fat. The number of coronary segments with disease (SIS) was calculated. RESULTS: A total of 36 patients were included in the analysis. Twenty-six (72%) patients had evidence of obstructive disease at CCTA and 25 (69%) patients had evidence of previous myocardial infarction. At non-contrast CT, we did not identify significant attenuation differences between epicardial, paracardial, subcutaneous, and visceral fat depots (-110.8 ± 9 HU, vs. -113.7 ± 9 HU, vs. -114.7 ± 8 HU, vs. -113.8 ± 11 HU, P = 0.36). Significant attenuation differences were detected between fat depots at mid and low energy levels, both at CTCA and delayed-enhancement scans ( P < 0.05 for all). Epicardial fat showed the least negative attenuation, irrespective of the acquisition mode; epicardial fat evaluated at 40 keV was related to the SIS (r = 0.37, P = 0.03). CONCLUSIONS: In this study, regional fat depots amenable to examination during thoracic CT scans have distinctive regional attenuation values. Furthermore, such differences were better displayed using contrast-enhanced monochromatic imaging at low energy levels.

Diagnostic Performance of a Novel Coronary CT Angiography Algorithm: Prospective Multicenter Validation of an Intracycle CT Motion Correction Algorithm for Diagnostic Accuracy.

OBJECTIVE: Motion artifact can reduce the diagnostic accuracy of coronary CT angiography (CCTA) for coronary artery disease (CAD). The purpose of this study was to compare the diagnostic performance of an algorithm dedicated to correcting coronary motion artifact with the performance of standard reconstruction methods in a prospective international multicenter study. SUBJECTS AND METHODS: Patients referred for clinically indicated invasive coronary angiography (ICA) for suspected CAD prospectively underwent an investigational CCTA examination free from heart rate-lowering medications before they underwent ICA. Blinded core laboratory interpretations of motion-corrected and standard reconstructions for obstructive CAD (≥ 50% stenosis) were compared with ICA findings. Segments unevaluable owing to artifact were considered obstructive. The primary endpoint was per-subject diagnostic accuracy of the intracycle motion correction algorithm for obstructive CAD found at ICA. RESULTS: Among 230 patients who underwent CCTA with the motion correction algorithm and standard reconstruction, 92 (40.0%) had obstructive CAD on the basis of ICA findings. At a mean heart rate of 68.0 ± 11.7 beats/min, the motion correction algorithm reduced the number of nondiagnostic scans compared with standard reconstruction (20.4% vs 34.8%; p < 0.001). Diagnostic accuracy for obstructive CAD with the motion correction algorithm (62%; 95% CI, 56-68%) was not significantly different from that of standard reconstruction on a per-subject basis (59%; 95% CI, 53-66%; p = 0.28) but was superior on a per-vessel basis: 77% (95% CI, 74-80%) versus 72% (95% CI, 69-75%) (p = 0.02). The motion correction algorithm was superior in subgroups of patients with severely obstructive (≥ 70%) stenosis, heart rate ≥ 70 beats/min, and vessels in the atrioventricular groove. CONCLUSION: The motion correction algorithm studied reduces artifacts and improves diagnostic performance for obstructive CAD on a per-vessel basis and in selected subgroups on a per-subject basis.

Exaggerated Interventricular Dependence Among Patients With Pectus Excavatum: Combined Assessment With Cardiac MRI and Chest CT.

OBJECTIVE: We sought to explore whether patients with pectus excavatum have exaggerated interventricular dependence and to evaluate the impact of the malformation severity (assessed on CT) on both anatomic and functional cardiac parameters (assessed on cardiac MRI). SUBJECTS AND METHODS: The current study involved consecutive patients with a diagnosis of pectus excavatum who were referred to undergo cardiac MRI and chest CT to establish surgical candidacy or to define treatment strategies. RESULTS: Sixty-two patients with pectus excavatum underwent cardiac MRI and chest CT. Fifty (81%) patients were male, and the median age was 17.5 years (range, 14.0-23.0 years). Forty-seven (76%) patients had evidence of right ventricular compression. The left ventricle showed a significantly decreased end-diastolic volume (inspiration vs expiration: 70.4 ± 11.6 vs 76.1 ± 13.7 mL/m2, respectively; p = 0.01) and a significantly higher eccentricity index (1.52 ± 0.2 vs 1.20 ± 0.1, p < 0.0001) during inspiration than during expiration. The median respiratory-related septal excursion was 8.1% (interquartile range, 5.1-11.7%). Patients with pericardial effusion showed a significantly higher pectus excavatum severity index than patients without pericardial effusion (6.3 ± 3.4 vs 4.4 ± 1.3, respectively; p = 0.003). Patients with a relative septal excursion equal to or larger than 11.8% showed a significantly higher pectus excavatum severity index than patients with a relative septal excursion of less than 11.8% (6.3 ± 2.6 vs 4.7 ± 2.4, respectively; p = 0.05). CONCLUSION: In this study, patients with pectus excavatum showed significant alterations of cardiac morphology and function that were related to the deformation severity and that manifest as an exaggerated interventricular dependence.

Detection of Myocardial Infarction Using Delayed Enhancement Dual-Energy CT in Stable Patients.

OBJECTIVE: The objective of our study was to explore whether delayed enhancement dual-energy CT (DECT) allows the detection of myocardial infarcts in stable patients. SUBJECTS AND METHODS: Patients with known or suspected coronary artery disease clinically referred for myocardial perfusion imaging using SPECT were prospectively included. All patients (n = 34) also underwent stress, rest, and delayed enhancement DECT on a DECT scanner. At SPECT, segments with myocardial infarction (MI) were defined as those with a summed rest score of ≥ 2 in two or more consecutive segments, and a diagnosis of MI was supported by wall motion abnormalities, clinical history, and ECG findings. RESULTS: Segments with MI were identified in 13 (38%), 15 (44%), and 14 (41%) patients using SPECT, perfusion CT, and delayed enhancement DECT, respectively. When combined SPECT and perfusion CT results were used as the reference standard, delayed enhancement DECT had a sensitivity, specificity, positive predictive value, and negative predictive value for the detection of MI of 91.7% (95% CI, 62-98%), 86.4% (95% CI, 65-97%), 78.6% (95% CI, 49-95%), and 95.0% (95% CI, 75-100%). At delayed enhancement DECT (40 keV), a signal attenuation higher than 161 HU had a sensitivity of 72% and a specificity of 79% for the detection of MI on a per-segment basis. The median signal attenuation of myocardial infarcts at 40 keV was 3.0 SDs (interquartile range, 1.3-4.0 SDs) above that of normal myocardium. CONCLUSION: In this study, delayed enhancement DECT allowed the detection of myocardial infarcts in stable patients.

Improved Discrimination of Myocardial Perfusion Defects at Low Energy Levels Using Virtual Monochromatic Imaging.

OBJECTIVES: The aim of this study was to explore the diagnostic performance of dual-energy computed tomography perfusion (DE-CTP) at different energy levels. METHODS: Patients with known or suspected coronary artery disease underwent stress and rest DE-CTP and single-photon emission computed tomography. Images were evaluated using monochromatic data, and perfusion defects were initially identified in a qualitative manner and subsequently confirmed using attenuation levels. RESULTS: Thirty-six patients were included. Sensitivity, specificity, positive predictive value, and negative predictive value of DE-CTP for the identification of perfusion defects were 84.1%, 94.2%, 77.3%, and 96.2%, respectively. Perfusion defects showed significantly lower attenuation than normal segments, with the largest differences among low energy levels (sensitivity of 96% and specificity of 98% using a cutoff value ≤ 153 Hounsfield units at 40 keV), progressively declining at the higher levels (P < 0.001). CONCLUSIONS: Dual-energy CTP at the lowest energy levels allowed improved discrimination of perfusion defects compared with higher energy levels.

Periprosthetic Artifact Reduction Using Virtual Monochromatic Imaging Derived From Gemstone Dual-Energy Computed Tomography and Dedicated Software.

OBJECTIVE: The aim of this study was to explore the usefulness of combined virtual monochromatic imaging and metal artifact reduction software (MARS) for the evaluation of musculoskeletal periprosthetic tissue. METHODS: Measurements were performed in periprosthetic and remote regions in 80 patients using a high-definition scanner. Polychromatic images with and without MARS and virtual monochromatic images were obtained. RESULTS: Periprosthetic polychromatic imaging (PI) showed significant differences compared with remote areas among the 3 tissues explored (P < 0.0001). No significant differences were observed between periprosthetic and remote tissues using monochromatic imaging with MARS (P = 0.053 bone, P = 0.32 soft tissue, and P = 0.13 fat). However, such differences were significant using PI with MARS among bone (P = 0.005) and fat (P = 0.02) tissues. All periprosthetic areas were noninterpretable using PI, compared with 11 (9%) using monochromatic imaging. CONCLUSIONS: The combined use of virtual monochromatic imaging and MARS reduced periprosthetic artifacts, achieving attenuation levels comparable to implant-free tissue.

Noninvasive Cardiac Imaging in Patients with Known and Suspected Coronary Artery Disease: What is in it for the Interventional Cardiologist?

The long-standing coronary artery disease (CAD) paradigm simplified by the discrimination between patients with or without CAD warrants to be revisited by the insightful information provided by noninvasive cardiac imaging, leading to a comprehensive physiopathological assessment rather than a mainly anatomical approach. This review will address (1) the role of non-invasive cardiac imaging for the appropriate selection of stable patients referred to invasive coronary angiography (ICA), and the evolving concept and prognostic implications of myocardial ischemia; (2) the usefulness of computed tomography coronary angiography for the guidance of percutaneous coronary interventions; and (3) the role and potential clinical impact of novel anatomical and functional non-invasive prognostic markers.

Rationale and design of the dual-energy computed tomography for ischemia determination compared to "gold standard" non-invasive and invasive techniques (DECIDE-Gold): A multicenter international efficacy diagnostic study of rest-stress dual-energy computed tomography angiography with perfusion.

BACKGROUND: Dual-energy CT (DECT) has potential to improve myocardial perfusion for physiologic assessment of coronary artery disease (CAD). Diagnostic performance of rest-stress DECT perfusion (DECTP) is unknown. OBJECTIVE: DECIDE-Gold is a prospective multicenter study to evaluate the accuracy of DECT to detect hemodynamic (HD) significant CAD, as compared to fractional flow reserve (FFR) as a reference standard. METHODS: Eligible participants are subjects with symptoms of CAD referred for invasive coronary angiography (ICA). Participants will undergo DECTP, which will be performed by pharmacological stress, and participants will subsequently proceed to ICA and FFR. HD-significant CAD will be defined as FFR ≤ 0.80. In those undergoing myocardial stress imaging (MPI) by positron emission tomography (PET), single photon emission computed tomography (SPECT) or cardiac magnetic resonance (CMR) imaging, ischemia will be graded by % ischemic myocardium. Blinded core laboratory interpretation will be performed for CCTA, DECTP, MPI, ICA, and FFR. RESULTS: Primary endpoint is accuracy of DECTP to detect ≥1 HD-significant stenosis at the subject level when compared to FFR. Secondary and tertiary endpoints are accuracies of combinations of DECTP at the subject and vessel levels compared to FFR and MPI. CONCLUSION: DECIDE-Gold will determine the performance of DECTP for diagnosing ischemia.

Sources of error in the measurement of aortic diameter in computed tomography scans.

OBJECTIVE: This study was conducted to determine the differences in the diameter of the thoracic aorta when measured from electrocardiographic (ECG)-gated and nongated computed tomography (CT) angiography. Another aim was to define the difference in the aortic diameter when it is measured at peak systole and end diastole in ECG-gated scans. METHODS: The gated and nongated CT angiograms of 27 patients (mean age, 58 ± 16 standard deviation [SD] years) obtained on a 256-slice multidetector CT scanner were used. The transverse and anteroposterior diameters and the lumen areas were measured at 1, 4, and 8 cm below the origin of the left subclavian artery. RESULTS: There was a significant difference in the aortic measurements of diameter between gated and nongated scans found in samples taken at 1, 4, and 8 cm distal to the left subclavian artery (P < .0001). We found a considerable difference between the systolic and diastolic diameters (P < .0001). The maximum change in diameter between systole and diastole was 2.9 ± 0.9 (SD) mm (14.5%, P < .0001) at 1 cm, 5.4 mm (22.6%; median, 1.7 mm; P < .0001) at 4 cm, and 4.4 mm (16.9%; median, 1.3 mm; P < .0001) at 8 cm. There was a significant difference between the transverse and anteroposterior diameters in systole and diastole at all locations (P < .0001): The maximum change in diameter between transverse and anteroposterior diameters in systole was 5.4 ± 1.1 (SD) mm (15.7%, P < .0001) at 1 cm, 5.8 mm (19%; median, 1.4 mm; P < .0001) at 4 cm, and 5 mm (15%; median, 1.02 mm; P < .0001) at 8 cm. There was also a substantial difference between measuring the transverse diameter directly and deriving it from the lumen area (P < .0001). CONCLUSIONS: Our results showed an important difference between systolic and diastolic diameters measurements in ECG-gated scans. The standard protocol for measuring aortic diameters in gated scans of the thoracic aorta uses images at end diastole because the lack of wall motion at this time provides better resolution. This is likely to result in undersizing that, in some instances, may threaten stability and the proper seal of the stent graft. The dimensions of the aorta in a gated CT should be measured at peak systole rather than the conventional end diastole used today. Most medical centers use nongated CT or gated CT scans in end diastole to calculate sizes of endografts. In view of our findings, the latter method could result in potential complications.

The Impact of COVID-19 on Diagnosis of Heart Disease in Latin America an INCAPS COVID Sub-analysis. / O Impacto da COVID-19 no Diagnóstico de Doenças Cardíacas na América Latina Uma Subanálise do INCAPS COVID.

BACKGROUND: The COVID-19 pandemic has disrupted the delivery of care for cardiovascular diseases in Latin America. However, the effect of the pandemic on the cardiac diagnostic procedure volumes has not been quantified. OBJECTIVE: To assess (1) the impact of COVID-19 on cardiac diagnostic volumes in Latin America and (2) determine its relationship with COVID-19 case incidence and social distancing measures. METHODS: The International Atomic Energy Agency conducted a worldwide survey assessing changes in cardiac diagnostic volumes resulting from COVID-19. Cardiac diagnostic volumes were obtained from participating sites for March and April 2020 and compared to March 2019. Social distancing data were collected from Google COVID-19 community mobility reports and COVID-19 incidence per country from the Our World in Data. RESULTS: Surveys were conducted in 194 centers performing cardiac diagnostic procedures, in 19 countries in Latin America. Procedure volumes decreased 36% from March 2019 to March 2020, and 82% from March 2019 to April 2020. The greatest decreases occurred in echocardiogram stress tests (91%), exercise treadmill tests (88%), and computed tomography calcium scores (87%), with slight variations between sub-regions of Latin America. Changes in social distancing patterns (p < 0.001) were more strongly associated with volume reduction than COVID-19 incidence (p = 0.003). CONCLUSIONS: COVID-19 was associated with a significant reduction in cardiac diagnostic procedures in Latin America, which was more related to social distancing than to the COVID-19 incidence. Better balance and timing of social distancing measures and planning to maintain access to medical care is warranted during a pandemic surge, especially in regions with high cardiovascular mortality.

FUNDAMENTO: A pandemia de COVID-19 interferiu na prestação de atendimento a doenças cardiovasculares na América Latina. No entanto, o efeito da pandemia nos volumes de procedimentos cardíacos diagnósticos ainda não foi quantificado. OBJETIVO: Avaliar (1) o impacto de COVID-19 nos volumes de diagnóstico cardíaco na América Latina e (2) determinar sua relação com a incidência de casos de COVID-19 e as medidas de distanciamento social. MÉTODOS: A International Atomic Energy Agency realizou uma pesquisa mundial avaliando mudanças nos volumes diagnósticos cardíacos decorrentes da COVID-19. Foram obtidos os volumes diagnósticos cardíacos dos locais participantes para março e abril de 2020 e comparados com março de 2019. Foram coletados dados de distanciamento social a partir dos Relatórios de mobilidade da comunidade de Google e a incidência de COVID-19 por país a partir de Our World in Data. RESULTADOS: Foram realizadas pesquisas em 194 centros que realizam procedimentos diagnósticos cardíacos, em 19 países da América Latina. Em comparação com o mês de março de 2019, os volumes dos procedimentos diagnósticos cardíacos diminuíram 36% em março de 2020 e 82% em abril de 2020.As maiores reduções ocorreram em relação aos testes de estresse ecocardiográfico (91%), testes ergométricos de esteira (88%) e escore de cálcio por tomografia computadorizada (87%), com pequenas variações entre as sub-regiões da América Latina. As mudanças em padrões de distanciamento social (p < 0,001) estavam mais fortemente associadas com a redução do volume do que a incidência de COVID-19 (p = 0,003). CONCLUSÕES: A COVID-19 foi associada a uma redução significativa de procedimentos diagnósticos cardíacos na América Latina, a qual foi mais relacionada ao distanciamento social do que ao aumento da incidência da COVID-19. São necessários melhor equilíbrio e timing de medidas de distanciamento social e planejamento para manter o acesso ao atendimento médico durante um surto pandêmico, especialmente em regiões com alta mortalidade cardiovascular.

Virtual hysterosalpingography: experience with over 1000 consecutive patients.

With the advent of multidetector computed tomography (MDCT), a whole new spectrum of diagnostic imaging techniques and procedures appears. Virtual hysterosalpingography (VHSG) is a novel non-invasive modality for assessing the uterus and female reproductive system that combines hysterosalpingography technique with MDCT technologies. Nowadays, 64-row VHSG offers an excellent diagnostic performance, in concordance with the development of new reproductive interventions and the need of accurate diagnostic procedures. In this article, we review the VHSG technique and describe normal and pathologic findings.

Virtual hysterosalpingography: a new multidetector CT technique for evaluating the female reproductive system.

Recent advances in reproductive medicine have generated a demand for more accurate imaging methods for identifying the specific cause of female infertility and other gynecologic disorders. Virtual hysterosalpingography is an emerging modality in which aspects of the established technique of hysterosalpingography are combined with the cutting-edge technology of multidetector computed tomography (CT) to allow a comprehensive and highly accurate evaluation of both the female reproductive system and the pelvic anatomy generally. Unlike ultrasonography (US) and magnetic resonance (MR) imaging, multidetector CT is capable of depicting both the external and internal surfaces of the uterus, fallopian tubes, and other pelvic organs, providing high-resolution data that are suitable for two- and three-dimensional reconstructions and virtual endoscopic views. Thus, virtual hysterosalpingography may prove to be superior to other noninvasive modalities for evaluating tubal patency. Moreover, in comparison with conventional hysterosalpingography, which may involve cervical clamping, virtual hysterosalpingography is painless. Because of the health risks associated with ionizing radiation, the use of another modality (eg, MR imaging, US) may be preferred if the presence of a focal uterine lesion is strongly suspected. However, virtual hysterosalpingography with multidetector CT may provide a diagnostic advantage in complex cases.

Anatomic or functional testing in stable patients with suspected CAD: contemporary role of cardiac CT in the ISCHEMIA trial era.

One of the foundations of the management of patients with suspected coronary artery disease (CAD) is to avoid unnecessary invasive coronary angiography (ICA) referrals. However, the diagnostic yield of ICA following abnormal conventional stress testing is low. The ability of ischemia testing to predict subsequent myocardial infarction and death is currently being challenged, and more than half of cardiac events among stable patients with suspected CAD occur in those with normal functional tests. The optimal management of patients with stable CAD remains controversial and ischemia-driven interventions, though improving anginal symptoms, have failed to reduce the risk of hard cardiovascular events. In this context, there is an ongoing debate whether the initial diagnostic test among patients with stable suspected CAD should be a functional test or coronary computed tomography angiography. Aside from considering the specific characteristics of individual patients and local availability and conditions, the choice of the initial test relates to whether the objective concerns its role as gatekeeper for ICA, prognosis, or treatment decision-making. Therefore, the aim of this review is to provide a contemporary overview of these issues and discuss the emerging role of CCTA as the upfront imaging tool for most patients with suspected CAD.

Diastolic and Systolic Cardiac Dysfunction in Pectus Excavatum: Relationship to Exercise and Malformation Severity.

PURPOSE: To explore stress echocardiographic findings among patients with pectus excavatum (PEX) and their relationship with malformation severity. MATERIALS AND METHODS: A prospective registry involving consecutive patients with a diagnosis of isolated PEX referred to undergo chest CT and stress echocardiography to evaluate surgical candidacy and/or to define treatment strategies was developed. Malformation indexes were evaluated using chest CT. RESULTS: This study included 269 patients with PEX (19.7 years ± 7.8 [standard deviation]; 245 men) and 35 healthy volunteers (20.7 years ± 6.1; 21 men). Patients with PEX achieved a lower maximal workload (PEX group, 8.2 metabolic equivalents ± 1.7; control group, 11.8 metabolic equivalents ± 5.5; P < .0001). This study identified evidence of abnormal right ventricular diastolic function in 29% of patients with PEX and identified no evidence of this among those in the control group (P < .0001). Healthy controls showed a 37% increment in the tricuspid area during exercise, compared with 4% in patients with PEX (P = .002). Right ventricular systolic function was significantly lower in patients with PEX than in controls, both measured using tricuspid annulus plane systolic excursion (stress, 25.0 mm ± 5.5 vs 35.4 mm ± 3.7; P < .0001), and the tricuspid systolic wave was also smaller (stress, 16.9 cm/sec ± 4.5 vs 20.5 cm/sec ± 3.9; P < .0001). During stress, significant associations were detected between malformation indexes with right ventricular systolic and diastolic findings (P < .05 for all). CONCLUSION: This study identified evidence of diverse adverse functional and morphologic cardiac manifestations in PEX, involving signs of abnormal diastolic and systolic right ventricular function and compression of the atrioventricular groove, which worsened during stress and were related to malformation severity.© RSNA, 2020: An earlier incorrect version of this article appeared online. This article was corrected on October 19, 2020.

Erratum: Diastolic and Systolic Cardiac Dysfunction in Pectus Excavatum: Relationship to Exercise and Malformation Severity.

[This corrects the article DOI: 10.1148/ryct.2020200011.].

Sternal torsion in pectus excavatum is related to cardiac compression and chest malformation indexes.

BACKGROUND/PURPOSE: The role of sternal torsion (ST) in patients with pectus excavatum (PEX) is unknown. We evaluated the relationship between ST and both chest malformation and cardiac compression (CC) indexes. METHODS: We included consecutive patients with PEX who underwent chest computed tomography and cardiac magnetic resonance (CMR) to define surgical candidacy. Malformation indexes included the Haller index (HI), correction index (CI), and ST. CC and the tricuspid to mitral annulus width ratio were evaluated using CMR. RESULTS: One-hundred and sixteen patients were included, with a mean HI of 5.8 ±â€¯3.6 and a mean CI of 35.8 ±â€¯18.0%. ST was significantly related to malformation indexes, being patients with absence of ST those showing the lowest HI (p = 0.048) and CI (p = 0.002). Right-sided ST was significantly related to the CC classification (p = 0.0001), and the tricuspid/mitral annulus width ratio was significantly lower among these patients (absence 0.98 ±â€¯0.15, left-sided 0.91 ±â€¯0.10, right-sided 0.80 ±â€¯0.15, p < 0.0001). A significant inverse relationship between ST degrees and the tricuspid/mitral ratio was also identified (r = -0.47, p < 0.0001). CONCLUSIONS: We identified a significant relationship between ST and both chest malformation and CC indexes; the absence of ST being identified as a marker of an overall more benign phenotype. TYPE OF STUDY: Study of diagnostic test. LEVEL OF EVIDENCE: Level II.

Impact of pectus excavatum on cardiac morphology and function according to the site of maximum compression: effect of physical exertion and respiratory cycle.

AIMS: Previous studies have demonstrated diverse cardiac manifestations in patients with pectus excavatum (PEX), although mostly addressing morphological or physiological impact as separate findings. Using multimodality imaging, we evaluated the impact of PEX on cardiac morphology and function according to the site of maximum compression, and the effect of exertion and breathing. METHODS AND RESULTS: All patients underwent chest computed tomography, cardiac magnetic resonance (CMR), and stress echocardiography (echo) in order to establish surgical candidacy. We evaluated diastolic function and trans-tricuspid gradient during stress (echo); and systolic function and respiratory-related septal wall motion abnormalities (CMR). Patients were classified according to the site of cardiac compression as type 0 (without cardiac compression); type 1 (right ventricle); and type 2 [right ventricle and atrioventricular (AV) groove]. Fifty-nine patients underwent multimodality imaging, with a mean age of 19.5 ± 5.9 years. Compared with a sex and age matched control group, peak exercise capacity was lower in patients with PEX (8.4 ± 2.0 METs vs. 15.1 ± 4.6 METs, P < 0.0001). At stress, significant differences were found between groups regarding left ventricular E/A (P = 0.004) and e/a ratio (P = 0.005), right ventricular E/A ratio (P = 0.03), and trans-tricuspid gradient (P = 0.001). At CMR, only 9 (15%) patients with PEX had normal septal motion, whereas 17 (29%) had septal flattening during inspiration. Septal motion abnormalities were significantly related to the cardiac compression classification (P < 0.0001). CONCLUSIONS: The present study demonstrated that patients with PEX, particularly those with compression affecting the right ventricle and AV groove, manifest diverse cardiac abnormalities that are mostly related to exertion, inspiration, and diastolic function.

Esophageal stenosis: three-dimensional multidetector CT and virtual endoscopy.

The improvement in spatial, temporal, and contrast resolutions with the newest multidetector computed tomographic (MDCT) scanners opens the opportunity to explore other applications of the virtual endoscopy technique besides the colon and stomach evaluation. As a non-invasive technique, virtual esophagoscopy represents an alternative to conventional endoscopy for the assessment of esophageal stenosis. The procedure and diagnostic performance are reviewed. Findings of this modality are illustrated.

Multidetector CT angiography and virtual angioscopy of the abdomen.

Computed tomographic angiography (CTA) has gained wide clinical acceptance as a powerful diagnostic tool in the non-invasive evaluation of vascular disorders and has became the method of choice for the assessment of aortic pathology. In addition, recent advances in computed tomography (CT) technology improve the image quality and diagnostic performance of the procedure in the abdominal vascular system. In this paper, we briefly review the CTA technique and describe the main applications of abdominal CTA.