ABSTRACT
Coronary artery fistulae are a rare congenital abnormality. If such fistulae drain directly into a cardiac chamber, they are termed coronary-cameral fistulae. Such fistulae are usually congenital in origin or, occasionally, may arise as an iatrogenic complication of a cardiac procedure such as cardiac catheterization or surgery. We present a highly unusual case in which a patient presented to cardiac services on two occasions-nearly a decade apart-and was found to have coronary aneurysms initially, the largest of which expanded further and into the right atrium, thus creating a coronary-cameral fistula.
Subject(s)
Coronary Aneurysm , Coronary Artery Disease , Coronary Vessel Anomalies , Heart Defects, Congenital , Vascular Fistula , Coronary Angiography , Coronary Vessel Anomalies/diagnostic imaging , Humans , Vascular Fistula/diagnostic imagingABSTRACT
BACKGROUND: COPD patients have increased risk of developing pneumonia, which is associated with poor outcomes. It can be symptomatically indistinguishable from exacerbations, making diagnosis challenging. Studies of pneumonia in COPD have focused on hospitalised patients and are not representative of the ambulant COPD population. Therefore, we sought to determine the incidence and aetiology of acute exacerbation events with evidence of pneumonic radiographic infiltrates in an outpatient COPD cohort. METHODS: One hundred twenty-seven patients with moderate to very severe COPD aged 42-85 years underwent blood and sputum sampling over one year, at monthly stable visits and within 72 h of exacerbation symptom onset. 343 exacerbations with chest radiographs were included. RESULTS: 20.1% of exacerbations had pneumonic infiltrates. Presence of infiltrate was highly seasonal (Winter vs summer OR 3.056, p = 0.027). In paired analyses these exacerbation events had greater increases in systemic inflammation. Bacterial detection rate was higher in the pneumonic group, with Haemophilus influenzae the most common bacteria in both radiological groups. Viral detection and sputum microbiota did not differ with chest radiograph appearance. CONCLUSIONS: In an outpatient COPD cohort, pneumonic infiltrates at exacerbation were common, and associated with more intense inflammation. Bacterial pathogen detection and lung microbiota were not distinct, suggesting that exacerbations and pneumonia in COPD share common infectious triggers and represent a continuum of severity rather than distinct aetiological events. TRIAL REGISTRATION: Trial registration Number: NCT01360398 .
Subject(s)
Disease Progression , Pneumonia/diagnostic imaging , Pneumonia/epidemiology , Pulmonary Disease, Chronic Obstructive/diagnostic imaging , Pulmonary Disease, Chronic Obstructive/epidemiology , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Humans , Male , Middle Aged , Pneumonia/physiopathology , Prospective Studies , Pulmonary Disease, Chronic Obstructive/physiopathologySubject(s)
Aorta, Thoracic/diagnostic imaging , Aorta, Thoracic/injuries , Heart Injuries/diagnostic imaging , Heart Injuries/etiology , Suicide, Attempted , Conservative Treatment , Coronary Angiography , Electrocardiography , Heart Injuries/therapy , Humans , Male , Middle Aged , Spinal Fractures/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: A score combining the burden of stenosis severity on coronary computed tomography angiography (CCTA) and flow impairment by fractional flow reserve derived from computed tomography (FFRCT) may be a better predictor of clinical events than either parameter alone. METHODS: The Functional FFRCT Score (FFS) combines CCTA and FFRCT parameters in an allocated point-based system. The feasibility of the FFS was assessed in cohort of 72 stable chest pain patients with matched CCTA and FFRCT datasets. Validation was performed using 2 cohorts: (a) 4468 patients from the ADVANCE Registry to define its association with revascularization and major adverse cardiovascular events (MACE); (b) 212 patients from the FORECAST trial to determine predictors of MACE. RESULTS: The median calculation time for the FFS was 10 (interquartile range 6-17) seconds, with strong intra-operator and inter-operator agreement (Cohen's Kappa 0.89 (±0.37, p â< â0.001) and 0.83 (±0.04, p â< â0.001, respectively). The FFS correlated strongly with both the CT-SYNTAX and the Functional CT-SYNTAX scores (rS â= â0.808 for both, p â< â0.001). In the ADVANCE cohort the FFS had good discriminatory abilities for revascularization with an area under the curve of 0.82, 95 â% confidence interval (CI) 0.81-0.84, p â< â0.001. Patients in the highest FFS tertile had significantly higher rates of revascularization (61 â% vs 5 â%, p â< â0.001) and MACE (1.9 â% vs 0.5 â%, p â= â0.001) compared with the lowest FFS tertile. In the FORECAST cohort the FFS was an independent predictor of MACE at 9-month follow-up (hazard ratio 1.04, 95 â% CI 1.01-1.08, p â< â0.01). CONCLUSION: The FFS is a quick-to-calculate and reproducible score, associated with revascularization and MACE in two distinct populations of stable symptomatic patients.
Subject(s)
Coronary Artery Disease , Coronary Stenosis , Fractional Flow Reserve, Myocardial , Humans , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/therapy , Coronary Angiography/methods , Predictive Value of Tests , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/therapy , Coronary Vessels/diagnostic imaging , Computed Tomography Angiography/methodsABSTRACT
OBJECTIVE: To evaluate the technical and oncological efficacy of an image-guided cryoablation programme for renal tumours. PATIENTS AND METHODS: A prospective analysis of technical and radiological outcomes was undertaken after treatment of 171 consecutive tumours in 147 patients. Oncological efficacy in a subset of 125 tumours in 104 patients with >6 months' radiological follow-up and a further subset of 62 patients with solitary, biopsy-proven renal carcinoma was also analysed. Factors influencing technical success, as determined by imaging follow-up, and complication rates were statistically analysed using a statistics software package and logistic regression analyses. RESULTS: No variables were found to predict subtotal treatment, although gender (P = 0.08), tumour size of >4 cm (P = 0.09) and central location of tumour (P = 0.07) approached significance. Upper pole location was the single variable that was found to predict complications (P = 0.006). Among the 104 patients (125 tumours), radiologically assessed at ≥6 months and with a mean radiological follow-up of 20.1 months, we found a single case of unexpected late local recurrence. CONCLUSION: Percutaneous image-guided cryoablation, at a mean of 20.1 months' follow-up, appears to provide a safe and effective treatment option with a low complication rate. Anteriorly sited tumours should not be considered a contraindication for percutaneous image-guided cryoablation.
Subject(s)
Carcinoma, Renal Cell/surgery , Cryosurgery/methods , Kidney Neoplasms/surgery , Surgery, Computer-Assisted/methods , Aged , Biopsy , Carcinoma, Renal Cell/pathology , Female , Follow-Up Studies , Humans , Incidence , Kidney Neoplasms/diagnosis , Kidney Neoplasms/mortality , Male , Neoplasm Recurrence, Local/epidemiology , Prospective Studies , Survival Rate/trends , Tomography, X-Ray Computed , Treatment Outcome , United Kingdom/epidemiologyABSTRACT
Pulmonary lacerations are an uncommon injury typically associated with high-impact trauma. Most cases occur as a result of high-speed road traffic collisions. Although chest wall and pleural injuries are commonly associated with sports-related thoracic trauma, pulmonary injuries are far less common. There are only a few reported cases of significant pulmonary trauma associated with sports injuries, the majority of which have described pulmonary contusions occurring as a result of thoracic injury sustained while playing high-impact contact sports such as American football. Pulmonary laceration occurring as result of soccer-related thoracic trauma has never previously been reported.
Subject(s)
Lacerations/etiology , Lung Injury/etiology , Soccer/injuries , Adolescent , Humans , Lacerations/diagnostic imaging , Lung Injury/diagnostic imaging , Male , Tomography, X-Ray ComputedABSTRACT
Superior vena cava (SVC) obstruction leads to a constellation of symptoms and signs that encompass the SVC syndrome. Today, malignancy accounts for 65% of all cases. The most common neoplastic causes are nonsmall cell lung cancer (50%), small cell lung cancer (25%), lymphoma, and metastasis. Primary cardiac tumors are an extremely rare cause of SVC obstruction. We describe the case of a 48-year-old man who presented with dyspnea, confusion, and facial swelling with cyanosis. The patient developed life-threatening airway obstruction after administration of anxiolytic. The diagnosis of SVC obstruction secondary to a primary cardiac sarcoma was established based on clinical, radiologic, and post-mortem findings. This is one of very few reported cases of a primary cardiac sarcoma causing SVC obstruction.
Subject(s)
Heart Neoplasms/complications , Sarcoma/complications , Superior Vena Cava Syndrome/etiology , Fatal Outcome , Heart Neoplasms/diagnostic imaging , Heart Neoplasms/pathology , Humans , Male , Middle Aged , Myocardium/pathology , Sarcoma/diagnostic imaging , Sarcoma/pathology , Superior Vena Cava Syndrome/diagnosis , Superior Vena Cava Syndrome/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
We describe a 61-year-old male patient at our institution who was being reviewed by the heart team for consideration of transcatheter aortic valve intervention. Gated cardiac computed tomography revealed extensive eccentric calcification of the left ventricular outflow tract (LVOT) extending into the mitral valve leaflet and a large aortic annulus (33 mm; mean annular diameter/area, 854 mmsup2;). This is larger than all recommended manufacturer annular size limits, although observational data support the use of both Edwards Sapien 3 and Medtronic Evolut R in such annuli.
Subject(s)
Aortic Valve Stenosis , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/surgery , Heart Valve Prosthesis/adverse effects , Humans , Male , Middle Aged , Prosthesis Design , Transcatheter Aortic Valve Replacement/adverse effects , Treatment OutcomeABSTRACT
Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.
Subject(s)
Aortic Valve Stenosis/diagnostic imaging , Aortic Valve/pathology , Calcinosis/diagnostic imaging , Coronary Artery Disease/diagnostic imaging , Incidental Findings , Tomography, X-Ray Computed/methods , Vascular Calcification/diagnostic imaging , Aortic Valve/diagnostic imaging , Consensus , Heart , Humans , Societies, Medical , United KingdomABSTRACT
Background: One of the most important techniques of cardiac magnetic resonance in assessment of coronary heart diseases is adenosine stress myocardial first-pass perfusion imaging. Using this imaging method, there should be an adequate response to the drug adenosine to make an accurate evaluation. The conventional signs of drug response are not always observed and are often subjective. Methods based on splenic perfusion might possess limitations as well. Therefore, T1 mapping presents as a novel, quantitative and reliable method. There are several studies analyzing this newly discovered property of different T1 mapping sequences. However most of these studies are enrolling only one of the techniques. Aims: To compare modified look-locker inversion recovery and shortened modified look-locker inversion recovery sequences in terms of T1 reactivity and to determine the relationship between T1 reactivity and conventional stress adequacy assessment methods in adenosine stress perfusion cardiac magnetic resonance. Study Design: A cross-sectional study using STARD reporting guideline. Methods: Thirty-four consecutive patients, who were referred for adenosine stress perfusion cardiac magnetic resonance with suspect of myocardial ischemia, were prospectively enrolled into the study. Four patients were disqualified, and thirty patients were included in the final analysis. Using both modified look-locker inversion recovery and shortened modified look-locker inversion recovery, midventricular short axis slices of T1 maps were acquired at rest and during peak adenosine stress before gadolinium administration. Then, they were divided into six segments according to the 17-segment model proposed by the American Heart Association, and separate measurements were made from each segment. Mean rest and mean stress T1 values of remote, ischemic, and infarcted myocardium were calculated individually per subject. During adenosine administration, patients' heart rates and blood pressures are measured and recorded every one minute. Adenosine stress perfusion images were examined for the presence of splenic switch-off. Results: There was a significant difference between rest and stress T1 values of remote myocardium in both modified look-locker inversion recovery and shortened modified look-locker inversion recovery (p<0.001). In both modified look-locker inversion recovery and shortened modified look-locker inversion recovery there was no significant correlation between T1 reactivity and heart rates response (modified look-locker inversion recovery p=0.30, shortened modified look-locker inversion recovery p=0.10), blood pressures response (modified look-locker inversion recovery p=0.062, shortened modified look-locker inversion recovery p=0.078), splenic perfusion (modified look-locker inversion recovery p=0.35, shortened modified look-locker inversion recovery p=0.053). There was no statistically significant difference between modified look-locker inversion recovery and shortened modified look-locker inversion recovery regarding T1 reactivity of remote (p=0.330), ischemic (p=0.068), and infarcted (p=0.116) myocardium. Conclusion: T1 reactivity is independent of the other stress response signs and modified look-locker inversion recovery and shortened modified look-locker inversion recovery do not differ in terms of T1 reactivity.
Subject(s)
Adenosine/administration & dosage , Magnetic Resonance Imaging/standards , Myocardial Perfusion Imaging/standards , Adenosine/pharmacology , Adenosine/therapeutic use , Aged , Analysis of Variance , Coronary Artery Disease/diagnosis , Coronary Artery Disease/physiopathology , Cross-Sectional Studies , Exercise Test/methods , Exercise Test/standards , Exercise Test/statistics & numerical data , Female , Humans , Magnetic Resonance Imaging/methods , Magnetic Resonance Imaging/statistics & numerical data , Male , Middle Aged , Myocardial Perfusion Imaging/methods , Myocardial Perfusion Imaging/statistics & numerical data , Predictive Value of TestsABSTRACT
OBJECTIVE: To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI). METHODS: A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant-findings that did not require specific treatment or follow-up; (b) intermediate-findings that did not impact on the decision-making process but required follow-up; (c) significant-findings that either required urgent investigation or meant that TAVI was clinically inappropriate. RESULTS: A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases. CONCLUSION: Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention. ADVANCES IN KNOWLEDGE: This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.
Subject(s)
Incidental Findings , Preoperative Care , Tomography, X-Ray Computed , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Clinical Decision-Making , Cohort Studies , Female , Humans , Male , Neoplasms/diagnostic imaging , Prevalence , Retrospective Studies , Risk , Tomography, X-Ray Computed/statistics & numerical data , Transcatheter Aortic Valve Replacement/statistics & numerical data , United KingdomSubject(s)
Abscess/diagnosis , Osteomyelitis/complications , Staphylococcal Infections/diagnosis , Tibia , Abscess/diagnostic imaging , Adult , Humans , Magnetic Resonance Imaging , Male , Osteomyelitis/diagnostic imaging , Radiography , Staphylococcal Infections/diagnostic imaging , Staphylococcus aureus/isolation & purification , Tibia/diagnostic imagingABSTRACT
The case involves a 69-year-old female with severe, longstanding bronchiectasis secondary to childhood pertussis infection. She presented to the hospital and was thought clinically to have a pulmonary embolus. A CT pulmonary angiogram was performed, which was technically satisfactory. This revealed multiple, bilateral filling defects that were fairly convincing for pulmonary emboli. Further review of the CT scan not only revealed the extent of her bronchiectasis but also a number of enlarged bronchial arteries supplying the diseased lung. The pulmonary arterial filling defects arose suspiciously close to the bronchial arteries and the possibility of bronchial to pulmonary artery anastomoses was considered. Could the admixture of highly contrast-opacified pulmonary arterial blood with partially opacified systemic arterial blood cause the apparent filling defects? After further consideration, a second electrocardiography-gated CT angiogram was performed-this time in the systemic arterial phase but planned with two regions of interest sited over the main pulmonary artery and the aorta with the aim of triggering the scan with maximum contrast in the bronchial arteries, and as much contrast washout as possible in the pulmonary arteries. This study revealed a reversal of the CT pulmonary angiogram appearances with contrast now seen in the bronchial arteries and opacifying the sites of the previous filling defects in the pulmonary arteries. Thus, the filling defects were actually false positives caused by an admixture of highly opacified and part-opacified blood via bronchial artery anastomoses. In the context of a false-positive finding of pulmonary embolus on a background of severe bronchiectasis, unnecessary anticoagulation could have increased the risk of complications such as haemoptysis. This case report illustrates the importance of knowledge of potential false-positive findings in CT pulmonary angiography and describes a novel approach based on cardiac CT techniques to prove this.
Subject(s)
Decompression, Surgical , Diaphragm/injuries , Hernia, Diaphragmatic/surgery , Adult , Decompression, Surgical/methods , Endoscopy, Digestive System/methods , Hernia, Diaphragmatic/diagnosis , Hernia, Diaphragmatic/etiology , Humans , Male , Tomography, X-Ray Computed , Wounds, Nonpenetrating/complicationsSubject(s)
Testis/injuries , Accidents, Traffic , Adolescent , Humans , Male , Rupture/diagnostic imaging , UltrasonographySubject(s)
Abscess/etiology , Mastoiditis/complications , Abscess/diagnosis , Adult , Earache/etiology , Humans , Male , NeckABSTRACT
BACKGROUND: Cryptococcosis refers to a spectrum of infections caused by the encapsulated yeast Cryptococcus neoformans. In the immunocompromised host cryptococcus may disseminate resulting in significant mortality and morbidity. CASE PRESENTATION: We report the case of a 49-year-old homosexual male presenting with an atypical skin lesion associated with an asymptomatic pulmonary nodule. A subsequent diagnosis of disseminated cryptococcosis was made on India ink staining of cerebrospinal fluid. CONCLUSION: A diagnosis of cryptococcosis should be considered in all patients at risk of immunocompromise that present with asymptomatic pulmonary nodules in the presence of extrapulmonary manifestations, as exemplified by the unusual skin ulceration in our case.