MR-arterioportography: a new technical approach for detection of liver lesions.

AIM: To evaluate the benefit and effectiveness of MR-arterioportography (MR-AP) to achieve the highest sensitivity for detection and evaluation of hepatocellular carcinoma (HCC). METHODS: Twenty liver cirrhosis patients with suspected HCC were included before transarterial chemoembolization. In all patients double-enhanced Magnetic resonance imaging (MRI) was performed. A bolus of 10 mL Magnevist® was injected through a selectively placed catheter in the superior mesenteric artery and MRI of the liver was performed in arterioportographic phase. Two independent readers evaluated number, size and localization of detected lesions. Diagnostic quality was determined using a 4-point scale. Differences were analyzed for significance using a t-test. Interobserver variability was calculated. RESULTS: In all 20 patients (100%), MR-AP was feasible. Diagnostic quality was, in all cases, between 1 and 2 for both modalities and readers. MR-AP detected significantly more lesions than double-enhanced MRI (102.5 vs. 61, respectively, P < 0.0024). The inter-observer variability was 0.881 for MRI and 0.903 for MR-AP. CONCLUSION: Our study confirmed that the MR-AP as an additional modality for detection of HCC is beneficial, as significantly more lesions were detected compared to MRI with liver-specific contrast.

Ultrasound-arterioportography (US-AP): A new technical approach to perform detection of liver lesions.

PURPOSE: To show the feasibility of a combination of the advantages of modern contrast enhanced ultrasound (CEUS) with the technique of arterioportography to achieve the highest sensitivity of all different modalities. MATERIAL AND METHODS: Ten patients (9 m, 1 f, age 52-73 years) with suspected hepatocellular carcinoma (HCC) in liver cirrhosis (8 ethyl toxic, 2 hepatitis) were included before transarterial chemo-embolization (TACE). In all patients during a 6-week period a double enhanced MRI (Gd-DTPA and SPIO) was performed. Before TACE a bolus <2 mL ultrasound contrast agent (SonoVue®, Bracco, Milan, Italy) was injected over a selectively placed catheter in the superior mesenteric artery (SMA) and ultrasound of the liver (2.5-4 MHz, LOGIQ 9; GE Healthcare) was performed in arterioportographic phase (US-AP). Two independent readers evaluate number, size and localisation of detected lesion in MRI and US-AP. Additional diagnostic quality of both modalities was determined using a 4-point scale (1: excellent-4: not diagnostic). Differences were analysed for significance using a t-test. Interobserver variability was calculated (κ-value). RESULT: In all 10 patients (100 %) US-AP was feasible. Diagnostic quality was in all cases between 1-2 for both modalities and readers (MRI standard deviation (SD) -0.51, Sono-AP SD -0.421). US-AP detected with 33.5 vs. 24.5 lesions, significant more lesions than double enhanced MRI (p < 0.022). The interobserver variability was κ -0.965 for MRI and κ -0.898 for US-AP. CONCLUSION: US-AP for detection of liver lesions is feasible. Using this technique significantly more lesions in patients with hepatocellular carcinoma could be detected in comparison to MRI with liver-specific contrast agent.

Variable phenotypes of bicuspid aortic valve disease: classification by cardiovascular magnetic resonance.

BACKGROUND: Recently, cardiovascular magnetic resonance (CMR) has been shown to allow accurate visualisation and quantification of aortic valve disease. Although bicuspid aortic valve (BAV) disease is relatively rare in the general population, the frequency is high in patients requiring valve surgery. The aim of the current study was to characterise the different phenotypes of BAV disease by CMR. METHODS: CMR studies were performed on a 1.5 T scanner in 105 patients with BAV. RESULTS: The pattern of BAV phenotypes was as follows: a raphe was identified in 90 patients (86%). Among patients with raphe, 76 patients had fusion between the right and left cusps (RL) and 14 patients had fusion between the right and the non-coronary cusps (RN). There were no significant differences in the aortic dimensions in the different BAV phenotypes. CONCLUSION: CMR allows excellent characterisation of valve phenotype in patients with BAV. The present data demonstrate that a raphe is present in the vast majority of cases and RL fusion is the predominant phenotype of BAV. No significant differences in the aortic dimensions were observed.

Cerebral lesions in patients with connective tissue diseases and systemic vasculitides: are there specific patterns?

This study was performed to evaluate whether specific patterns of cerebral lesions can be identified in different rheumatic disease entities. In 132 patients with different connective tissue diseases and vasculitides (systemic lupus erythematosus [SLE], systemic sclerosis [SSc], mixed connective tissue disease [MCTD], Wegener's granulomatosis [WG], immunocomplex vasculitides, antiphospholipid antibody syndrome [APS]), cerebral magnetic resonance imaging scans were performed. Patients were examined clinically, and laboratory parameters including autoantibodies were determined. Distinct distibution patterns could be identified; in WG, most lesions were seen in the cortex, the periventricular region, basal ganglia, and pons. In both SSc and MCTD, highest numbers of lesions could be detected in the corticomedullary junction. In APS, basal ganglia and periventricular white matter were involved predominantly. Generally, the maximum score of cerebral lesions correlated significantly with patients' age. Pathological values for antinuclear antibodies and increased levels of antiphospholipid antibodies were significantly correlated with the presence of cerebral lesions. WG patients and patients with other vasculitides most frequently showed neurological abnormalities. This study in patients with different rheumatic diseases showed distinct distribution patterns of cerebral lesions, which might help to differentiate between them.

Superselective arterial embolisation with a liquid polyvinyl alcohol copolymer in patients with acute gastrointestinal haemorrhage.

OBJECTIVES: To evaluate the results of emergency embolisation in acute arterial bleeding of the gastrointestinal tract with a liquid polyvinyl alcohol copolymer from two centres. METHODS: We retrospectively analysed 16 cases (15 patients) of acute arterial bleeding of the gastrointestinal tract where emergency embolotherapy was performed by using the copolymer when acute haemorrhage was not treatable with endoscopic techniques alone. Cause of haemorrhage and technical and clinical success were documented. RESULTS: Arterial embolotherapy was successful in all 16 cases. The technical success rate was 100%. The cause of bleeding was pancreatitis in four, graft-versus-host disease (GVHD) of the colon in three, malignancy in three, angiodysplasia in two, ulcer in two and panarteritis nodosa and trauma in one each. There were no procedure-related complications. No bowel necrosis occurred because of embolisation. In 13 cases, the patients were discharged in good condition (81%); the three patients with GVHD died because of the underlying disease. CONCLUSIONS: The copolymer seems to have great potential in embolotherapy of acute arterial gastrointestinal bleeding. In our series none of the patients had rebleeding at the site of embolisation and no clinically obvious bowel necrosis occurred.

Ultrasound-guided sacroiliac joint injection in patients with established sacroiliitis: precise IA injection verified by MRI scanning does not predict clinical outcome.

OBJECTIVE: IA injections of SIJs with corticosteroids are often performed in patients suffering from low back pain due to active sacroiliitis. However, SIJ injections are technically demanding, and therefore the clinical outcome of ultrasound-guided corticosteroid SIJ injections was analysed in relation to the accuracy of the injection. METHODS: Ultrasound-guided injections were performed with 40 mg triamcinolone and 0.78 mg gadolinium in 20 SIJ of 14 consecutive patients suffering from active sacroiliitis. Immediately following SIJ injection, MRI scanning was initiated to verify the correct placement of the drug. Clinical outcome of the intervention was determined using a numerical pain rating scale (NRS) at Days 1 and 28. RESULTS: Despite ultrasound guidance, only 8 injections (40%) were exactly positioned into the SIJ space, whereas the other 12 injections (60%) missed the SIJ. However, there were no significant differences observed in the clinical outcome between the IA-injected group and the peri-articular-injected group. There was similar pain relief observed in both groups 24 h and 28 days following the intervention [IA injection group: mean NRS-baseline: 6.8 (range 4-9), NRS-24 h: 4.3 (range 1-7) and NRS-day 28: 3.5 (range 1-5); peri-articular injection group: mean NRS-baseline: 7.0 (range 5-10), NRS-24 h: 4.1 (range 1-10) and NRS-day 28: 4.5 (range 1-8)]. CONCLUSION: These results demonstrate that IA SIJ injections remain technically challenging despite ultrasound guidance. However, peri-articular deposition of triamcinolone appears sufficient for pain and symptom control in patients suffering from active sacroiliitis.

Optimized multidetector computed tomographic protocol for the diagnosis of active obscure gastrointestinal bleeding: a feasibility study.

OBJECTIVE: The purpose of this feasibility study was to prospectively evaluate an optimized multidetector computed tomographic protocol for the diagnosis of active obscure gastrointestinal bleeding (OGIB). METHODS: Between October 2006 and February 2008, patients admitted for active OGIB were included in this prospective unicenter study. Water was administered orally and rectally as neutral luminal contrast material. A contrast-enhanced 16-row multidetector computed tomography (MDCT) was performed in the arterial and venous phases. Mesenteric digital subtraction angiography was carried out immediately after MDCT as standard of reference. RESULTS: Six patients were included in this study. Multidetector computed tomography identified the bleeding site and source in 5 (83%) of the patients. Digital subtraction angiography was performed in 4 patients, and the result was positive in 1 (25%) of the patients. Multidetector computed tomography detected the site and source of bleeding in 2 patients whose digital subtraction angiographic result was negative. CONCLUSIONS: The results of this feasibility study indicate that optimized MDCT is an excellent diagnostic tool for the diagnosis of active OGIB.

Outcome in a large unselected series of patients with acute pancreatitis.

BACKGROUND/AIMS: The objective of this study was to assess the outcome in a large unselected population of patients with acute pancreatitis treated at a single university center. METHODOLOGY: We performed a retrospective analysis of 364 patients with acute pancreatitis and evaluated outcome, morbidity and mortality in relation to different treatment modalities. RESULTS: 238 patients suffered from interstitial-edematous pancreatitis, 126 patients from the necrotizing form. ICU treatment was necessary for 174 patients (48%). Minimally-invasive CT guided drainage techniques were used in 73 patients (20%) with pancreatic necroses but also in seven patients with edematous pancreatitis (2%), which showed extrapancreatic tissue necrosis. The overall hospital mortality was 14% (5.5% for patients with edematous pancreatitis vs. 30% for patients with necrotizing pancreatitis). CONCLUSIONS: In patients with the edematous form a small subpopulation showed peripancreatic tissue necrosis without necrosis of the pancreas itself, which was related to higher mortality rates than expected for patients with edematous pancreatitis. Regarding therapeutic procedures interventional treatment modalities should be considered as alternative treatment modalities.

Electrocardiographic diagnosis of left ventricular hypertrophy in aortic valve disease: evaluation of ECG criteria by cardiovascular magnetic resonance.

BACKGROUND: Left ventricular hypertrophy (LVH) is a hallmark of chronic pressure or volume overload of the left ventricle and is associated with risk of cardiovascular morbidity and mortality. The purpose was to evaluate different electrocardiographic criteria for LVH as determined by cardiovascular magnetic resonance (CMR). Additionally, the effects of concentric and eccentric LVH on depolarization and repolarization were assessed. METHODS: 120 patients with aortic valve disease and 30 healthy volunteers were analysed. As ECG criteria for LVH, we assessed the Sokolow-Lyon voltage/product, Gubner-Ungerleider voltage, Cornell voltage/product, Perugia-score and Romhilt-Estes score. RESULTS: All ECG criteria demonstrated a significant correlation with LV mass and chamber size. The highest predictive values were achieved by the Romhilt-Estes score 4 points with a sensitivity of 86% and specificity of 81%. There was no difference in all ECG criteria between concentric and eccentric LVH. However, the intrinsicoid deflection (V6 37 +/- 1.0 ms vs. 43 +/- 1.6 ms, p < 0.05) was shorter in concentric LVH than in eccentric LVH and amplitudes of ST-segment (V5 -0.06 +/- 0.01 vs. -0.02 +/- 0.01) and T-wave (V5 -0.03 +/- 0.04 vs. 0.18 +/- 0.05) in the anterolateral leads (p < 0.05) were deeper. CONCLUSION: By calibration with CMR, a wide range of predictive values was found for the various ECG criteria for LVH with the most favourable results for the Romhilt-Estes score. As electrocardiographic correlate for concentric LVH as compared with eccentric LVH, a shorter intrinsicoid deflection and a significant ST-segment and T-wave depression in the anterolateral leads was noted.

Frequency and nature of incidental extra-enteric lesions found on magnetic resonance enterography (MR-E) in patients with inflammatory bowel diseases (IBD).

BACKGROUND: The aim of this study was to determine the occurrence of extra-enteric findings in a large cohort of patients undergoing magnetic resonance enterography (MR-E) and to classify the clinical significance of these findings. MATERIALS AND METHODS: We retrospectively analyzed 1154 MR-E performed in 1006 patients referred to our radiological department between 1999-2005. The reasons for referral were suspected or proven inflammatory bowel diseases (IBD) (n = 710), further diagnostic work-up for small bowel disease because of non-specific abdominal symptoms (SBD; n = 182) or suspected small bowel malignancies (SBM; n = 114). All extra-enteric findings were reviewed by a radiologist and a gastroenterologist and were classified as having high, moderate, or low significance for further diagnostic or therapeutic procedures. RESULTS: The average age of all patients was 40+/-16 (Mean+/-SD) years (y) (IBD 35+/-13 y; SBD 49+/-16 y; SBM 57+/-15 y). A total of 1113 extra-enteric findings were detected in 600 of 1006 patients (59.6%). Of these findings 180 (16.2%) were judged as having a high, 212 (19.0%) a moderate and 721 (64.8%) a low significance. On a per group basis in patients with IBD 12.0% of the findings were of major clinical significance compared to 13.7% and 33.3% in patients with SBD and SBM, respectively. The most common major findings were abscesses (69.9%) in the IBD group and extraintestinal tumors, metastases or masses in the SBD and SBM groups (41.9% and 74.2%, respectively). CONCLUSIONS: MR-E reveals a substantial number of extra-enteric findings, supporting the role of a cross-sectional imaging method for the evaluation of the small bowel.

Obscure gastrointestinal bleeding: preoperative CT-guided percutaneous needle localization of the bleeding small bowel segment.

A 57-year-old woman presented with obscure gastrointestinal bleeding. Double balloon enteroscopy, angiography, and surgery including intraoperative enteroscopy failed to identify the bleeding site. Multidetector computed tomography (CT) depicted active bleeding of a small bowel segment. The bleeding segment was localized by CT-guided percutaneous needle insertion and subsequently removed surgically.

Diagnostic accuracy of intraarterial and i.v. MR angiography for the detection of stenoses of the infrainguinal arteries.

OBJECTIVE: The objective of our study was to prospectively evaluate the diagnostic accuracy of intraarterial (i.a.) and i.v. MR angiography (MRA) of the infrainguinal arteries in comparison with the reference standard selective digital subtraction angiography (DSA). SUBJECTS AND METHODS: Twenty consecutive patients with symptomatic peripheral arterial occlusive disease (PAOD) underwent i.v. MRA and i.a. MRA of the infrainguinal arteries and DSA, which served as the reference standard. For i.v. MRA, 27 mL of gadodiamide was injected through a peripheral arm vein; for i.a. MRA, 30 mL of diluted contrast agent (5 mL of gadodiamide in 55 mL of 0.9% saline solution) was twice injected in the superficial femoral artery with a flow rate of 2.5 mL/s through a 5-French sheath that was placed on the occasion of DSA before vascular intervention. A 3D gradient-echo sequence was performed using a dedicated coil system on a 1.5-T MR scanner. Three independent blinded observers localized and quantitatively graded stenoses on i.v. MRA and i.a. MRA. The overall impression of image quality of i.v. MRA and i.a. MRA was documented using a 4-point scale (1, excellent; 4, poor). Interobserver agreement was calculated. RESULTS: The mean sensitivity and mean specificity for the detection of stenoses >or= 50% of the upper leg arteries (i.e., superficial femoral artery and popliteal artery) were 85.5% and 83.3% for i.a. MRA and 82.2% and 86.7% for i.v. MRA, respectively. The mean sensitivity and mean specificity for the detection of stenoses >or= 50% of the lower leg arteries (i.e., proximal anterior tibial artery, tibiofibular trunk, proximal posterior tibial artery, and proximal peroneal artery) were 91.7% and 75.0% for i.a. MRA, respectively, and 87.5% each for i.v. MRA. the diagnostic quality of i.a. MRA images and i.v. MRA images was assessed as excellent or good. CONCLUSION: i.a. MRA provides sensitivity and specificity for the detection of hemodynamically significant stenoses of the infrainguinal arteries comparable to i.v. MRA and therefore is a good diagnostic tool especially for MR-guided vascular interventions.

Dilatation of the ascending aorta in bicuspid aortic valve disease: a magnetic resonance imaging study.

BACKGROUND: Bicuspid aortic valve disease (BAV) is increasingly recognized as a disease of the entire proximal aorta including both valvular and vascular complications. The aim of our study was to assess the dimensions of the thoracic aorta using MRI in a broad spectrum of BAV and tricuspid aortic valve disease (TAV) and to define the prevalence of the dilatation of the ascending aorta (AA) >or= 4.5 cm in severe BAV disease. METHODS AND RESULTS: MRI studies were performed on a 1.5 T scanner in a total of 195 consecutive patients with aortic valve disease. Eighty-four aortic valves were classified as BAV and 103 as TAV. In 8 patients, classification of the aortic valve was not possible due to poor image quality. Mean diameters of the AA were significantly greater in BAV compared to TAV (4.39+/-0.85 Vs. 3.55+/-0.47 cm, P<0.0001), whereas no differences were observed in the mean diameters of the aortic arch. Diameters of the descending aorta were slightly smaller in BAV compared to TAV (2.45+/-0.43 Vs. 2.58+/-0.31 cm, P<0.05). In BAV, AA dilatation was independent of the severity of valve dysfunction. In TAV, aortic regurgitation but not stenosis correlated weakly with AA dilatation. Prevalence of AA dilatation >or= 4.5 cm in BAV with severe aortic stenosis and regurgitation was 38% and 41%, respectively. CONCLUSION: Dilatation of the proximal aorta is a frequent finding in BAV and independent of the severity of valve dysfunction. With respect to the high prevalence of AA dilatation >or= 4.5 cm in BAV with severe valve dysfunction, careful assessment of the dimensions of the AA is crucial to identify patients in whom concomitant AA replacement is indicated according to current guidelines.

Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention for patients with symptomatic or asymptomatic carotid artery stenosis. Although several prospective randomized trials indicate that carotid artery stenting (CAS) is an alternative but not superior treatment modality, there is still a significant lack of long-term data comparing CAS with CEA. This study presents long-term results of a prospective, randomized, single-center trial. METHODS: Between August 1999 and April 2002, 87 patients with a symptomatic high-grade internal carotid artery stenosis (>70%) were randomized to CAS or CEA. After a median observation time of 66 +/- 14.2 months (CAS) and 64 +/- 12.1 months (CEA), 42 patients in each group were re-evaluated retrospectively by clinical examination and documentation of neurologic events. Duplex ultrasound imaging was performed in 61 patients (32 CAS, 29 CEA), and patients with restenosis >70% were re-evaluated by angiography. RESULTS: During the observation period, 23 patients (25.2%) died (10 CAS, 13 CEA), and three were lost to follow up. The incidence of strokes was higher after CAS, with four strokes in 42 CAS patients vs none in 42 CEA patients. One transient ischemic attack occurred in each group. A significantly higher rate of restenosis >70% (6 of 32 vs 0 of 29) occurred after CAS compared with CEA. Five of 32 CAS patients (15.6%) presented with high-grade (>70%) restenosis as an indication for secondary intervention or surgical stent removal, and three presented with neurologic symptoms. No CEA patients required reintervention (P < .05 vs CAS). A medium-grade (<70%) restenosis was detected in eight of 32 CAS patients (25%) and in one of 29 CEA patients (3.4%). In five of 32 CAS (15.6%) and three of 29 CEA patients (10.3%), a high-grade stenosis of the contralateral carotid artery was observed and treated during the observation period. CONCLUSION: The long-term results of this prospective, randomized, single-center study revealed a high incidence of relevant restenosis and neurologic symptoms after CAS. CEA seems to be superior to CAS concerning the development of restenosis and significant prevention of stroke. However, the long-term results of the ongoing multicenter trials have to be awaited for a final conclusion.

Time course of eosinophilic myocarditis visualized by CMR.

We report the diagnostic potential of cardiovascular magnetic resonance (CMR) to visualize the time course of eosinophilic myocarditis upon successful treatment. A 50-year-old man was admitted with a progressive heart failure. Endomyocardial biopsies were taken from the left ventricle because of a white blood cell count of 17000/mm3 with 41% eosinophils. Histological evaluation revealed endomyocardial eosinophilic infiltration and areas of myocyte necrosis. The patient was diagnosed with hypereosinophilic myocarditis due to idiopathic hypereosinophilic syndrome. CMR-studies at presentation and a follow-up study 3 weeks later showed diffuse subendocardial LGE in the whole left ventricle. Upon treatment with steroids, CMR-studies revealed marked reduction of subendocardial LGE after 3 months in parallel with further clinical improvement. This case therefore highlights the clinical importance of CMR to visualize the extent of endomyocardial involvement in the diagnosis and treatment of eosinophilic myocarditis.

Triphasic mitral inflow pattern and regional triphasic mitral annulus velocity in hypertrophic cardiomyopathy.

In Doppler echocardiography, a triphasic mitral inflow filling pattern with a mid-diastolic flow velocity (L) is usually related to elevated filling pressures and delayed myocardial relaxation. Furthermore, additional triphasic mitral annulus velocity with a mid-diastolic component (L') at tissue Doppler imaging (TDI) demonstrates an even more advanced diastolic dysfunction. In this puzzling case, a triphasic and restrictive mitral inflow pattern was noted in 55-year-old patient with Hypertrophic Cardiomyopathy and a history of septal myectomy. Interestingly, E' was reduced (< 0.1 m/s) and a mid-diastolic component (L') was recorded by TDI in the septal corner of the mitral annulus. However, E' was near normal (> or = 0.1 m/s) in the lateral mitral annulus. Upon contrast-enhanced cardiac MRI, severe septal scarring could be visualized as delayed hyperenhancement corresponding to the region of restrictive and triphasic diastolic function. Therefore, advanced regional diastolic dysfunction in the septum could be demonstrated by localized triphasic mitral annulus velocity as a correlate of pronounced scarring.

Delayed visceral arterial hemorrhage following Whipple's procedure: minimally invasive treatment with covered stents.

BACKGROUND: Delayed visceral arterial hemorrhage caused by inflammatory vessel erosion represents a rare but life-threatening complication after pancreatic head resection. Therapeutic options include reoperation or endovascular minimally invasive techniques such as embolization or stent graft placement. The present article describes our experiences with implantation of newly developed low-profile stent grafts. METHODS: The findings of four patients with delayed visceral arterial hemorrhage are described. All patients were treated with placement of low-profile stent grafts. The patients' medical records, radiological reports, and images were retrospectively reviewed. Technical success was defined as immediate cessation of hemorrhage. Clinical success was defined as hemodynamic stability. RESULTS: A total of seven stent grafts were implanted in four arteries. In detail, one stent graft was placed in the splenic artery of the first and second patients. In the third patient one stent graft was initially implanted in the common hepatic artery. The patient developed recurrent hemorrhages of the common hepatic artery, treated one time surgically and two times by deployment of a second and third stent graft. In the fourth patient two stent grafts were placed in the proper hepatic artery. Technical and clinical success was achieved at every procedure. Apart from recurrent hemorrhage of patient No. 3 there were no major complications. CONCLUSIONS: Minimally invasive therapy using low-profile stent grafts is an effective and safe procedure for the treatment of delayed visceral arterial hemorrhage following Whipple's procedure. The technique is a promising alternative to standard procedures such as surgical repair or embolization.

Cardiovascular magnetic resonance for direct assessment of anatomic regurgitant orifice in mitral regurgitation.

BACKGROUND: In patients with mitral regurgitation (MR), assessment of the severity of valvular dysfunction is crucial. Recently, regurgitant orifice area has been proposed as the most useful indicator of the severity of MR. The purpose of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with MR is feasible by cardiovascular magnetic resonance (CMR) and correlates with invasive catheterization and echocardiography effective regurgitant orifice [ECHO-ERO] by proximal isovelocity surface area. METHODS AND RESULTS: Planimetry of ARO was performed with a 1.5-T CMR scanner using a breath-hold balanced gradient echo sequence true fast imaging with steady state precession (TrueFISP). CMR planimetry of ARO was possible in 35 of 38 patients and was closely correlated with angiographic grading (r=0.84, P<0.0001). In patients with MR grade > or =III on catheterization, CMR-ARO (0.60+/-0.29 cm(2) versus 0.30+/-0.19 cm(2), P<0.0001) as well as ECHO-ERO (0.49+/-0.17 cm(2) versus 0.27+/-0.10 cm(2)) were significantly elevated in comparison with MR grade or =III as defined by catheterization, with a sensitivity and specificity of 94% and 94%, respectively. CONCLUSIONS: CMR planimetry of the anatomic mitral regurgitant lesion in patients with MR is feasible and permits quantification of MR with good agreement with the accepted invasive and noninvasive methods. Direct measurement by CMR is a promising new method for the precise assessment of ARO area and the severity of MR.

A case of recurrent gastrointestinal bleeding and protein-losing gastroenteropathy.

BACKGROUND: A 40-year-old male with pentalogy of Fallot (a congenital heart defect with five anatomical components) presented with recurrent gastrointestinal bleeding. He had recently recovered from a heart operation, which was performed to reconstruct the right ventricular outflow tract. INVESTIGATIONS: Laboratory tests and absorption tests, esophagogastroduodenoscopy, capsule endoscopy, human serum albumin scintigraphy, lymphoscintigraphy, CT and abdominal lymph-node histology. DIAGNOSIS: Intestinal lymphangiectasia with concurrent protein-losing gastroenteropathy and recurrent gastrointestinal bleeding. MANAGEMENT Despite a low-fat diet and surgical suturing of multiple small-bowel ulcerations the gastrointestinal bleeding continued. Serum albumin levels remained very low and severe lymphedema occurred. Unfortunately, the patient developed severe sepsis and died of multiple organ failure.

Technology insight: advances in liver imaging.

The role of diagnostic imaging in the assessment of liver disease continues to gain in importance. The classic techniques used for liver imaging are ultrasonography, CT and MRI. In the past decade, there have been significant advances in all three techniques. In this article, we discuss the advances in ultrasonography, CT and MRI that have improved assessment of focal and diffuse liver disease, including the development of hardware, software, processing algorithms and procedural innovations.