Percutaneous intervention of a giant native coronary artery aneurysm using self-expanding stents.

In the absence of standardized management guidelines, coronary artery aneurysms (CAAs) present therapeutic challenges. Percutaneous coronary intervention (PCI) is rarely explored, especially in giant aneurysms with persistent angina, where surgery might be presumed as a preferred option. We describe the technical aspects and feasibility of PCI using Gore Viabahn expanded polytetrafluoroethylene (ePTFE)-covered nitinol self-expanding stents in a 66-year-old woman with a complex medical history and an enlarging, symptomatic right coronary artery aneurysm. The case was complicated by endoleak after the first stent, but intravascular ultrasound guidance enabled the precise deployment of additional stents, resulting in the successful exclusion of the aneurysm. This case demonstrates steps to successful CAA PCI with Gore Viabahn ePTFE-covered nitinol self-expanding stents and emphasizes that in unsuitable surgical candidates, PCI might be a potential alternative for symptomatic CAAs.

Radiologic-Pathologic Correlation of Cardiac Tumors: Updated 2021 WHO Tumor Classification.

Cardiac tumors, although rare, carry high morbidity and mortality rates. They are commonly first identified either at echocardiography or incidentally at thoracoabdominal CT performed for noncardiac indications. Multimodality imaging often helps to determine the cause of these masses. Cardiac tumors comprise a distinct category in the World Health Organization (WHO) classification of tumors. The updated 2021 WHO classification of tumors of the heart incorporates new entities and reclassifies others. In the new classification system, papillary fibroelastoma is recognized as the most common primary cardiac neoplasm. Pseudotumors including thrombi and anatomic variants (eg, crista terminalis, accessory papillary muscles, or coumadin ridge) are the most common intracardiac masses identified at imaging. Cardiac metastases are substantially more common than primary cardiac tumors. Although echocardiography is usually the first examination, cardiac MRI is the modality of choice for the identification and characterization of cardiac masses. Cardiac CT serves as an alternative in patients who cannot tolerate MRI. PET performed with CT or MRI enables metabolic characterization of malignant cardiac masses. Imaging individualized to a particular tumor type and location is crucial for treatment planning. Tumor terminology changes as our understanding of tumor biology and behavior evolves. Familiarity with the updated classification system is important as a guide to radiologic investigation and medical or surgical management. ©RSNA, 2024 Supplemental material is available for this article.

Plasma Cell-Free DNA Predicts Survival and Maps Specific Sources of Injury in Pulmonary Arterial Hypertension.

BACKGROUND: Cell-free DNA (cfDNA) is a noninvasive marker of cellular injury. Its significance in pulmonary arterial hypertension (PAH) is unknown. METHODS: Plasma cfDNA was measured in 2 PAH cohorts (A, n=48; B, n=161) and controls (n=48). Data were collected for REVEAL 2.0 (Registry to Evaluate Early and Long-Term PAH Disease Management) scores and outcome determinations. Patients were divided into the following REVEAL risk groups: low (≤6), medium (7-8), and high (≥9). Total cfDNA concentrations were compared among controls and PAH risk groups by 1-way analysis of variance. Log-rank tests compared survival between cfDNA tertiles and REVEAL risk groups. Areas under the receiver operating characteristic curve were estimated from logistic regression models. A sample subset from cohort B (n=96) and controls (n=16) underwent bisulfite sequencing followed by a deconvolution algorithm to map cell-specific cfDNA methylation patterns, with concentrations compared using t tests. RESULTS: In cohort A, median (interquartile range) age was 62 years (47-71), with 75% female, and median (interquartile range) REVEAL 2.0 was 6 (4-9). In cohort B, median (interquartile range) age was 59 years (49-71), with 69% female, and median (interquartile range) REVEAL 2.0 was 7 (6-9). In both cohorts, cfDNA concentrations differed among patients with PAH of varying REVEAL risk and controls (analysis of variance P≤0.002) and were greater in the high-risk compared with the low-risk category (P≤0.002). In cohort B, death or lung transplant occurred in 14 of 54, 23 of 53, and 35 of 54 patients in the lowest, middle, and highest cfDNA tertiles, respectively. cfDNA levels stratified as tertiles (log-rank: P=0.0001) and REVEAL risk groups (log-rank: P<0.0001) each predicted transplant-free survival. The addition of cfDNA to REVEAL improved discrimination (area under the receiver operating characteristic curve, 0.72-0.78; P=0.02). Compared with controls, methylation analysis in patients with PAH revealed increased cfDNA originating from erythrocyte progenitors, neutrophils, monocytes, adipocytes, natural killer cells, vascular endothelium, and cardiac myocytes (Bonferroni adjusted P<0.05). cfDNA concentrations derived from erythrocyte progenitor cells, cardiac myocytes, and vascular endothelium were greater in patients with PAH with high-risk versus low-risk REVEAL scores (P≤0.02). CONCLUSIONS: Circulating cfDNA is elevated in patients with PAH, correlates with disease severity, and predicts worse survival. Results from cfDNA methylation analyses in patients with PAH are consistent with prevailing paradigms of disease pathogenesis.

Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study.

INTRODUCTION: Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke. METHODS: We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). RESULTS: The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]). CONCLUSION: In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.

Nanomechanical study of aqueous-processed h-BN reinforced PVA composites.

Hexagonal boron nitride (h-BN) as a filler has significantly improved the mechanical properties of various polymers composites. Among them, polyvinyl alcohol (PVA) is particularly important for its wide range of industrial applications and biocompatibility nature. However, preparing a homogenous composite of h-BN and PVA in water is troublesome as the aqueous processing of h-BN without any additives is challenging. In this context, a pre-processing technique is used to produce an additive-free aqueous dispersion of h-BN. The uniformly dispersed composites are then prepared with different concentrations of h-BN. Free-standing thin films are fabricated using the doctor blade technique, and nanoindentation is employed to understand their deformation behaviour at smaller length scale for better understanding of micro-mechanism involved. Reduced elastic modulus and hardness of 10 wt% h-BN/PVA composite film are enhanced by ∼93% and ∼159%, respectively, compared to pristine PVA. Frequency sweep dynamic mechanical analysis is performed between 1 and 50 Hz, and the elastic properties of composite materials are found to improve significantly upon addition of h-BN nanosheets. Besides, the impact of h-BN incorporation in stress relaxation behaviour and hardness depth profiling are also investigated. The observed improvement in mechanical properties of the composites may be attributed to the uniform distribution of the nanosheets and the strong interfacial interaction between h-BN and PVA, which ensures efficient mechanical stress transfer at the interface.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures.

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ©RSNA, 2021.

Effect of platelet inhibitors on thrombus burden in patients with acute pulmonary embolism.

Venous thromboembolism (VTE) whether provoked or not can be life-threatening due to an acute increase in load on the right ventricle (RV) from obstruction of the pulmonary artery (PA). Treatment for and prevention of VTE involves anti-thrombotic agents; more specifically, medications targeting the anticoagulation cascade. In spite of the widespread acceptance of anticoagulants in the treatment of VTE, there appears to be an ongoing belief that platelet reactivity contributes to thrombus burden in patients with acute pulmonary embolism (PE). This investigation of 398 patients presenting with acute PE evaluated whether anti-platelet medication use, which consisted mostly of aspirin therapy, at the time of presentation, affects PA thrombus burden, RV load, or short-term patient outcomes. We conclude that platelets may have been erroneously incriminated as direct thrombotic mediators in patients with acute PE since aspirin neither decreased PA thrombus burden, nor did aspirin improve short-term mortality following acute PE.

Genetic Admixture and Survival in Diverse Populations with Pulmonary Arterial Hypertension.

Rationale: Limited information is available on racial/ethnic differences in pulmonary arterial hypertension (PAH).Objectives: Determine effects of race/ethnicity and ancestry on mortality and disease outcomes in diverse patients with PAH.Methods: Patients with Group 1 PAH were included from two national registries with genome-wide data and two local cohorts, and further incorporated in a global meta-analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for transplant-free, all-cause mortality in Hispanic patients with non-Hispanic white (NHW) patients as the reference group. Odds ratios (ORs) for inpatient-specific mortality in patients with PAH were also calculated for race/ethnic groups from an additional National Inpatient Sample dataset not included in the meta-analysis.Measurements and Main Results: After covariate adjustment, self-reported Hispanic patients (n = 290) exhibited significantly reduced mortality versus NHW patients (n = 1,970) after global meta-analysis (HR, 0.60 [95% CI, 0.41-0.87]; P = 0.008). Although not significant, increasing Native American genetic ancestry appeared to account for part of the observed mortality benefit (HR, 0.48 [95% CI, 0.23-1.01]; P = 0.053) in the two national registries. Finally, in the National Inpatient Sample, an inpatient mortality benefit was also observed for Hispanic patients (n = 1,524) versus NHW patients (n = 8,829; OR, 0.65 [95% CI, 0.50-0.84]; P = 0.001). An inpatient mortality benefit was observed for Native American patients (n = 185; OR, 0.38 [95% CI, 0.15-0.93]; P = 0.034).Conclusions: This study demonstrates a reproducible survival benefit for Hispanic patients with Group 1 PAH in multiple clinical settings. Our results implicate contributions of genetic ancestry to differential survival in PAH.

Enhancing communication skills among residents in India: An interprofessional education approach.

BACKGROUND: Interprofessional education (IPE) provides opportunities to postgraduates to develop communication skills which are vital for interactions with patients, their relatives, colleagues, paramedical and nursing staff. There is a need to develop an innovative IPE based module on communication skills for postgraduates stressing upon the existing lacunae and requirements detected by a validated assessment tool. We assessed the residents' appraisal of communication skills by a validated questionnaire to identify key areas to improve their communication skills and to determine perceptions of all the stakeholders i.e. faculty, nursing staff and paramedical staff. METHODS: A descriptive correlational design using an online self-administered questionnaire on a sample of a total of 200 participants comprising residents, paramedical staff, nursing staff and faculty of tertiary care hospital. Study was approved by the Institutional Ethical Committee. Data was analysed by SPSS Version 22.0 used. (p value < 0.05 significant). RESULTS: The participants included 113 residents, 17 paramedical staff, 33 Nursing staff and 37 faculty members. The present study found a significant difference of scores of means between the residents, faculty, paramedical staff and nursing staff p value < 0.05 except for alter centrism, interaction management and environmental control. The mean scores were also significantly different between the first, second and third year residents. CONCLUSION: This study validates the need to enhance the communication skills of residents. The scores obtained will help us design and refine IPE module for the benefit of the residents.

Acute Fractures and Dislocations of the Ankle and Foot in Children.

Distinct biologic and mechanical attributes of the pediatric skeleton translate into fracture patterns, complications, and treatment dilemmas that differ from those of adults. In children, increasing participation in competitive sports activities has led to an increased incidence of acute injuries that affect the foot and ankle. These injuries represent approximately 13% of all pediatric osseous injuries. Important posttraumatic complications include premature physeal arrest, three-dimensional deformities and consequent articular incongruity, compartment syndrome, and infection. The authors describe normal developmental phenomena and injury mechanisms of the ankle and foot and associated imaging findings; mimics and complications of acute fractures; and dislocations that affect the pediatric ankle and foot. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. The different types of ankle and foot fractures are described, and the American College of Radiology guidelines used to determine appropriate imaging recommendations for patients who meet the Ottawa ankle and foot rules are discussed. The systems used to classify clinically important fractures, including the Salter-Harris, Dias-Tachdjian, Rapariz, and Hawkins systems, are described, with illustrations that reinforce key concepts. These classification systems aid in diagnosis and treatment planning, facilitate communication, and help standardize documentation and research. This information is intended to supplement radiologists' understanding of developmental phenomena, anatomic variants, fracture patterns, and associated complications that affect the pediatric foot and ankle. In addition, the role of imaging in ensuring appropriate treatment, follow-up, and patient and parent counseling is highlighted. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.

Reduced Serum Levels of Cluster of Differentiation 200 in Alcohol-Dependent Patients.

AIM: Chronic alcohol consumption can activate and dysregulate the neuroimmune system which leads to neuroinflammation. Neuroimmune regulatory proteins (NIReg) (e.g. Cluster of Differentiation 200 (CD200)) are the regulators of innate immune response and are responsible for silencing the innate immunity and suppression of inflammation. In this study, we explored the changes of serum levels of CD200 in patients with alcohol dependence at baseline, after one-week alcohol withdrawal and after one-month of alcohol abstinence. METHODS: Seventeen patients with alcohol dependence admitted for de-addiction treatment and 12 healthy controls were enrolled in the study. Blood samples were collected at baseline, after one-week, and after one-month, and CD200 levels were measured using enzyme-linked immunosorbent assay kit and compared with the healthy controls. RESULTS: The serum level of the neuroimmune regulatory protein CD200 in alcohol dependent group (at baseline) was significantly lower compared to healthy controls (p=0.003), and increased after one-week, and one-month period. CONCLUSION: The present study indicates that decrease of CD200 serum levels in alcohol dependent patients and its rise during alcohol withdrawal and abstinence may provide a preliminary evidence of the role of neuroimmune regulatory proteins in neuroadaptation during alcohol withdrawal.

Bands in the Heart: Multimodality Imaging Review.

Multiple bands and bandlike structures can be found within the cardiac chambers, which can be evaluated with various imaging modalities including echocardiography, CT, MRI, and invasive angiography. These bands can be classified as normal structures or normal variants, aberrant structures, or pathologic entities. Normal structures include the crista terminalis, taenia sagittalis, Chiari network, coumadin ridge, moderator band, papillary muscles, and chordae tendineae. Aberrant structures include aberrant papillary muscles, accessory chordae, false tendons, and accessory mitral valve tissue. Pathologic entities include double-chambered right ventricle, double-chambered left ventricle, cor triatriatum, and subaortic stenosis. Several types of bands are incidental findings discovered at imaging and do not produce clinical symptoms. However, some bands can mimic cardiac diseases, including masses. More importantly, some bands are pathologic entities that produce symptoms owing to hemodynamic consequences. Performing multimodality imaging helps the radiologist (a) identify, localize, and characterize the bands; (b) determine if they are normal structures, abnormal structures, or pathologic entities; (c) distinguish them from cardiac pathologic conditions; and (d) evaluate the secondary consequences of pathologic entities. This article reviews the various bands visualized within the cardiac chambers, as well as the role of imaging in depicting the bands, their appearances across various imaging modalities, and their clinical significance. Online supplemental material is available for this article. ©RSNA, 2019.

Coronary Plaque Characterization in Psoriasis Reveals High-Risk Features That Improve After Treatment in a Prospective Observational Study.

BACKGROUND: Psoriasis, a chronic inflammatory disease associated with an accelerated risk of myocardial infarction, provides an ideal human model to study inflammatory atherogenesis in vivo. We hypothesized that the increased cardiovascular risk observed in psoriasis would be partially attributable to an elevated subclinical coronary artery disease burden composed of noncalcified plaques with high-risk features. However, inadequate efforts have been made to directly measure coronary artery disease in this vulnerable population. As such, we sought to compare total coronary plaque burden and noncalcified coronary plaque burden (NCB) and high-risk plaque (HRP) prevalence between patients with psoriasis (n=105), patients with hyperlipidemia eligible for statin therapy under National Cholesterol Education Program-Adult Treatment Panel III guidelines (n=100) who were ≈10 years older, and healthy volunteers without psoriasis (n=25). METHODS: Patients underwent coronary computed-tomography angiography for total coronary plaque burden and NCB quantification and HRP identification, defined as low attenuation (<30 hounsfield units), positive remodeling (>1.10), and spotty calcification. A consecutive sample of the first 50 patients with psoriasis was scanned again 1 year after therapy. RESULTS: Despite being younger and at lower traditional risk than patients with hyperlipidemia, patients with psoriasis had increased NCB (mean±SD: 1.18±0.33 versus 1.11±0.32, P=0.02) and similar HRP prevalence (P=0.58). Furthermore, compared to healthy volunteers, patients with psoriasis had increased total coronary plaque burden (1.22±0.31 versus 1.04±0.22, P=0.001), NCB (1.18±0.33 versus 1.03±0.21, P=0.004), and HRP prevalence beyond traditional risk (odds ratio, 6.0; 95% confidence interval, 1.1-31.7; P=0.03). Last, among patients with psoriasis followed for 1 year, improvement in psoriasis severity was associated with improvement in total coronary plaque burden (ß=0.45, 0.23-0.67; P<0.001) and NCB (ß=0.53, 0.32-0.74; P<0.001) beyond traditional risk factors. CONCLUSIONS: Patients with psoriasis had greater NCB and increased HRP prevalence than healthy volunteers. In addition, patients with psoriasis had elevated NCB and equivalent HRP prevalence as older patients with hyperlipidemia. Last, modulation of target organ inflammation (eg, skin) was associated with an improvement in NCB at 1 year, suggesting that control of remote sites of inflammation may translate into reduced coronary artery disease risk.

CT for evaluation of acute pericardial emergencies in the ED.

Acute pericardial emergencies may present with acute chest pain. Although complete diagnosis and physiological effects of acute pericardial disease may require a combination of different imaging, CT plays a critical role in identifying the cause of chest pain in the ED. Many of these pericardial diseases can be fatal unless emergent treatment is obtained. The presentation can often be non-specific and symptoms can be overlapping with other diseases originating in the thorax or abdomen. Optimizing the CT scan is imperative when acute pericardial disease is suspected from clinical examination or preliminary imaging. The interpreting radiologist needs to be aware of the different entities which represent acute pericardial emergencies requiring urgent therapeutic intervention. Time is the essence, the clock is ticking, and every minute counts!

State-of-the-art pulmonary arterial imaging - Part 2.

Although pulmonary embolism is the most common abnormality of the pulmonary artery, there is a broad spectrum of other congenital and acquired pulmonary arterial abnormalities. Multiple imaging modalities are now available to evaluate these abnormalities of the pulmonary arteries. CT and MRI are the most commonly used cross-sectional imaging modalities that provide comprehensive information on several aspects of these abnormalities, including morphology, function, risk-stratification and therapy-monitoring. In this article, we review the role of state-of-the-art pulmonary arterial imaging in the evaluation of non-thromboembolic disorders of pulmonary artery.

Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment.

The ribs are frequently affected by blunt or penetrating injury to the thorax. In the emergency department setting, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury, specific traumatic patterns, and acute rib trauma complications that require emergent attention. Rib injuries can be separated into specific morphologic fracture patterns that include stress, buckle, nondisplaced, displaced, segmental, and pathologic fractures. Specific attention is also required for flail chest and for fractures due to pediatric nonaccidental trauma. Rib fractures are associated with significant morbidity and mortality, both of which increase as the number of fractured ribs increases. Key complications associated with rib fracture include pain, hemothorax, pneumothorax, extrapleural hematoma, pulmonary contusion, pulmonary laceration, acute vascular injury, and abdominal solid-organ injury. Congenital anomalies, including supernumerary or accessory ribs, vestigial anterior ribs, bifid ribs, and synostoses, are common and should not be confused with traumatic pathologic conditions. Nontraumatic mimics of traumatic rib injury, with or without fracture, include metastatic disease, primary osseous neoplasms (osteosarcoma, chondrosarcoma, Ewing sarcoma, Langerhans cell histiocytosis, and osteochondroma), fibrous dysplasia, and Paget disease. Principles of management include supportive and procedural methods of alleviating pain, treating complications, and stabilizing posttraumatic deformity. By recognizing and accurately reporting the imaging findings, the radiologist will add value to the care of patients with thoracic trauma. Online supplemental material is available for this article. ©RSNA, 2017.

Every second counts: signs of a failing heart on thoracic CT in the ED.

Impending cardiac failure is often difficult to recognize and requires a multidisciplinary approach. Upon arrival in the emergency department, patients are promptly screened for potentially life-threatening conditions through a history and physical examination. In many cases, the diagnosis is not clear until confirmatory laboratory or imaging tests are performed. Unfortunately, patients can rapidly decompensate as this diagnostic information is being obtained. Emergent CT plays a key role in identifying conditions that may result in cardiovascular collapse, including severe congestive heart failure, myocardial infarction, cardiac tamponade, and impending cardiac failure. Characteristic imaging findings can prompt the physician to take immediate action and prepare for resuscitation.

Identification of Left Ventricle Failure on Pulmonary Artery CTA: Diagnostic Significance of Decreased Aortic & Left Ventricle Enhancement.

PURPOSE: This study aimed to identify findings on non-ECG-gated CT pulmonary angiography (CTPA) indicating decreased left ventricle (LV) systolic function, later confirmed by echocardiogram. METHODS: After obtaining institutional review board approval, review was performed of emergency department (ED) patients who had CTPA and follow-up echocardiogram within 48 h, over 18 months. Patients with pulmonary embolus, suboptimal CTPA, arrhythmias or pericardial tamponade were excluded. One hundred thirty-seven patients were identified and divided into cases (LVEF <40%, n = 52) and controls (LVEF >50%, n = 85). Two reviewers performed these analyses: measurement of enhancement in main pulmonary artery (MPA), LV, and aorta; subjective enhancement of LV and aorta (Ao) relative to MPA using a four-point Likert scale; contrast transit time (TD) to trigger CTPA and LV short & long axis dimensions. When available, the most recent N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was recorded. RESULTS: Decreased aortic and LV subjective enhancement were the best predictors of LV systolic dysfunction. For Ao/MPA ratio, an optimal cutoff value of 0.20 resulted in a sensitivity of 0.54 and specificity of 0.93 (AUC = 0.83, 0.78-0.88 95% CI). A threshold of 86.7 HU for Ao enhancement resulted in a sensitivity of 0.68 and specificity of 0.90 (AUC = 0.82, 0.77-0.88 95% CI). A LV short axis diameter of more than 54.3 mm had a sensitivity of 0.62 and specificity of 0.98 (AUC = 0.88, 0.83-0.92 95% CI). For the LV long axis diameter, a cutoff of 87.5 mm resulted in a sensitivity of 0.66 and specificity of 0.84 (AUC = 0.78, 0.72-0.84 95% CI). With bolus timing, cases had a longer TD (13.4 vs. 10.4 s, p < 0.0001). CONCLUSION: Unsuspected LV systolic dysfunction can be recognized on a CTPA by identification of decreased aortic enhancement, LV enlargement and increased TD. This has important diagnostic implications for the patient presenting with shortness of breath, chest pain, or dyspnea.

Quantitating aortic regurgitation by cardiovascular magnetic resonance: significant variations due to slice location and breath holding.

OBJECTIVES: Compare variability in flow measurements by phase contrast MRI, performed at different locations in the aorta and pulmonary artery (PA) using breath-held (BH) and free-breathing (FB) sequences. METHODS: Fifty-seven patients with valvular heart disease, confirmed by echocardiography, were scanned using BH technique at 3 locations in the ascending aorta (SOV = sinus of Valsalva, STJ = sinotubular junction, ASC = ascending aorta at level of right pulmonary artery) and 2 locations in PA. Single FB measurement was obtained at STJ for aorta. Obtained metrics (SV = stroke volume, FV = forward volume, BV = backward volume, RF = regurgitant fraction) were evaluated separately for patients with aortic regurgitation (AR, n = 31) and mitral regurgitation (n = 26). RESULTS: No difference was noted between the two measurements in the PA. Significant differences were noted in measured SV at different aortic locations. SV measurements obtained at ASC correlated best with the measurements obtained in the PA. Strongest correlation of AR was measured at the STJ. CONCLUSION: Measurements of flow volumes by phase contrast MRI differ depending on slice location. When using stroke volumes to calculate pulmonary to systemic blood flow ratio (Qp/Qs), ASC should be used. For quantifying aortic regurgitation, measurement should be obtained at STJ. KEY POINTS: • Aortic regurgitation can be accurately measured by MRI. • Aortic regurgitation measurement by MRI varies according to the location where measured. • Aortic regurgitation can also be measured by MRI without breath hold.