Intimal sarcoma of the pulmonary valve.

Pulmonary artery intimal sarcoma is a rare tumor of the cardiovascular system. Intimal sarcoma of the pulmonary valve itself has not been described. Embolization into pulmonary arteries originating from the pulmonary valve intimal sarcoma can mimic chronic thromboembolic pulmonary hypertension and mislead the diagnosis. We present and discuss a patient initially diagnosed as chronic thromboembolic pulmonary hypertension, treated by pulmonary endarterectomy. After 24 months, a tumor of the pulmonary valve was detected by echocardiography. The patient underwent removal and replacement of the pulmonary valve. Histology revealed pulmonary valve intimal sarcoma.

Superior vestibular neurectomy: a novel transmeatal approach for a denervation of the superior and lateral semicircular canals.

OBJECTIVE: To assess morphologically a transmeatal approach to the lateral and superior ampullary nerves performable under local anesthesia and simultaneously with the existing approach to the singular nerve developed by Gacek during the same operation. MATERIALS AND METHODS: Eighty halves of human heads preserved with the Thiel method were operated on by an otologist. Two surgical approaches were tested on each specimen, 1 superior and 1 inferior to the tympanic segment of the facial nerve. The 80 specimens were divided into 2 groups. In the first group, the osseous canal of the nerves of the lateral and superior semicircular canal were previously probed and next operated. In the second group, the osseous canal of the nerves were operated prior assessment by dissection. Afterward, all 80 halves underwent computed tomographic investigation to measure the distance between the entrance point of the drill in the medial wall of the tympanic cavity and the osseous canal the ampullary nerves. RESULTS: Inferior approach to the canal of the nerves could not be done without wide opening of the vestibulum in all 80 specimens. In the superior approach, the nerve could be reached directly in 5 cases, and only via the osseous ampulla of the lateral semicircular canal in 28 cases in the first group. In 7 cases, the nerves could not be reached without damage to the membranous labyrinth. In the second group, the nerve could be reached directly in 2 cases, via the osseous ampulla in 36 cases, and was unreachable in 2 cases. Significantly, distances longer than 3 mm between the surgical access and the nerve were found on the inaccessible cases. CONCLUSION: A transmeatal approach is possible superiorly but not inferiorly to the facial nerve, although it is necessary to open the osseous ampulla but not the membranous labyrinth in most cases.

The emerging role of magnetic resonance imaging in the diagnosis and management of pulmonary hypertension.

Pulmonary hypertension is a life-threatening chronic disorder of the pulmonary circulation. Elevated pressure and resistance in the pulmonary vessels lead to progressive right heart failure which results in functional limitations and ultimately the death of most patients. Thus, the monitoring of right ventricular (RV) function is of great importance. Cardiac magnetic resonance imaging (cardiac MRI) has several advantages over other imaging methods. The use of cine acquisition techniques allows precise description of characteristic volumetric and functional variables, such as right ventricular volumes, muscle mass, stroke volume, ejection fraction, or cardiac output. Impaired right ventricular contractility and function have also been assessed using measures like ventricular septal bowing and pressure-volume loops. MRI investigations have been performed to monitor medical treatment, and the improvement in well-established prognostic factors, such as the 6-min walk, were correlated with measures of right ventricular function. Flow-derived parameters of the pulmonary arteries (such as peak velocity, acceleration time and volume, or pulmonary flow profile) are available using velocity-encoded imaging, and may detect early signs of remodelling. Additionally, magnetic resonance angiography is a promising new tool to visualise pulmonary perfusion and to diagnose chronic thromboembolic pulmonary hypertension. The purpose of this review is to summarise recent advances of cardiovascular magnetic resonance imaging, which will play an increasing role in the comprehensive diagnostic work-up of patients with pulmonary hypertension as a tool to monitor the course of the disease and to evaluate new therapeutic approaches.

Influence of a tilting prosthetic mitral valve orientation on the left ventricular flow - an experimental in vivo magnetic resonance imaging study.

OBJECTIVE: Orientation-related monoleaflet mechanical valve flow and velocity studies in the downstream are limited in mitral valve replacement studies. METHODS: In five sheep, ventricular blood flow was visualized prior to the implantation of a Medtronic Hall tilting valve model. In six sheep, the implant orientation was either anatomical (disc aligned with the anterior leaflet) or anti-anatomical. The mitral subvalvular apparatus was preserved. Sheep were positioned within an 1.5 T field strength MR scanner (Magnetom Sonata; Siemens) to assess time-dependent three dimensional blood flow. RESULTS: The preoperative ventricular velocity profiles presented negligible individual variances. Streamlines passed homogeneously without any spatial differences in flow velocities into the left ventricle. Starting from the anatomical position, blood entered mainly through the major orifice of the mechanical valve. The single artificial leaflet mimicked the rudder effect of the natural anterior mitral leaflet, preventing blood streaming directly towards the septum. The area with inhomogeneous blood velocities in the ventricle increased but not significantly from the preoperative status. The non-axial inflow not directed directly to the apex converted to a similar helix as observed in the preoperative cases. Anti-anatomical orientation of the prosthesis caused a significant increase in turbulence immediately after passing the mitral prosthesis. The main stream was changed so significantly that the blood flow shifted towards the septum and caused higher velocities of the stream profiles and turbulence apically. CONCLUSIONS: To achieve optimal hemodynamics, orientation of the mitral tilting valve has to be considered carefully, as has been long known from aortic valve replacement studies.

On the value of geometry-based models for left ventricular volumetry in magnetic resonance imaging and electron beam tomography: a Bland-Altman analysis.

OBJECTIVE: Methodological comparison of ellipsoid model-based approaches and Simpson method to evaluate left ventricular volumetric parameters by magnetic resonance (MR) and electron beam tomography (EBT) and analysis of the origin of possible discrepancies. METHODS AND MATERIAL: 100 subjects (87 patients, 13 healthy volunteers) were studied in MR in various cardiac views and EBT long axis view to determine left ventricular volumes and masses by applying (rotational) ellipsoid and Simpson model. Observer variation and method agreement was quantified by means of variance component and Bland-Altman analysis. RESULTS: Simpson approach showed smaller observer variability than all ellipsoid approaches. All geometry-based models gave smaller left ventricular volumes than Simpson approach, the bias in mass determination was minimal. Whereas high correlation coefficients (typically 0.85-0.95) for left ventricular volume and mass measurements indicated satisfying correspondence between methods, large 95% limits of agreement made a transfer of results for single subjects between Simpson and ellipsoid approaches difficult and between different geometry-based models almost impossible. Because 95% limits of agreement and observer variability of geometry-based approaches were of equal order, the latter could be identified as main limiting factor of methodological agreement. CONCLUSION: MR Simpson approach is superior to all ellipsoid model-based approaches, because observer variability is smaller.

CT and MR imaging of pericardial disease.

The diagnosis and therapy of pericardial diseases are still a physician's challenge. Advanced CT and MR imaging technologies can display the complete morphology of the heart and the pericardium and of the adjacent thoracic structures with a spatial and contrast resolution below 1 mm. All the macromorphologic determinants of pericardial constriction and their functional sequels may be identified by these remarkable technologies. A careful systematic image analysis defines not only a precise diagnosis but also determines the optimal surgical or conservative therapy for the individual patient and minimizes the risk of perisurgical mortality.

MR imaging-based port placement planning for totally endoscopic coronary artery bypass grafting.

An easy applicable method for pre-operative port position planning for totally endoscopic coronary artery bypass (TECAB) grafting based on magnetic resonance (MR) coronary angiography and image post-processing is introduced and analyzed. For this, combined left main (LM) and left anterior descending (LAD) coronary arteries of 21 subjects (14 patients, 7 healthy volunteers with similar habitus) were investigated in MR by means of transversally orientated, three-dimensional (3D), fat-saturated, breath-hold true fast imaging with steady state precession sequences with real-time navigator-based slice following. For the healthy volunteers, the vertical dimension of the total 3D slab was enlarged to enable TECAB planning. Optimal endoscopic port positions were determined via image analysis and geometric methods. 13.8+/-2.1 cm mean continuously visible length of combined LM and LAD coronary arteries (no statistical difference between patients and healthy volunteers) allowed visualizing typical regions for suturing of the anastomosis in all 21 cases. The mean horizontal distance of the optimal endoscopic port position from the center of the sternum was 7.0+/-1.3 cm. In conclusion, MR imaging-based port position planning is feasible. Variability in the determined port positions indicates the necessity of adaptation of port positioning even for subjects with similar habitus.

Angiotensin-converting enzyme polymorphisms and their potential impact on left ventricular myocardial geometry after aortic valve surgery.

BACKGROUND AND AIM OF THE STUDY: Genetic variants of the angiotensin-converting enzyme (ACE) cascade may influence left ventricular myocardial mass (LVMM) regression after aortic valve surgery. Postoperative long-term changes in LV indices were investigated in patients with asymptomatic aortic regurgitation (AR) and symptomatic aortic stenosis (AS) and related to alleles of ACE polymorphisms. METHODS: A total of 96 patients was included in the study, 21 with class IIa AR (22%) and 75 with class I AS (78%) recommendations for surgery. Patients were evaluated for demographic risk factors and underwent a thorough clinical examination including 3-D cardiac imaging by ultrafast-computed tomography. Genomic DNA was isolated for genotyping. RESULTS: AR patients were younger (55.8 +/- 8.9 versus 64 +/- 9.1 years, p = 0.0014), had a larger body surface area (1.92 +/- 0.21 versus 1.82 +/- 0.19 m2, p = 0.039), and were more likely to be asymptomatic (myocardial infarction, p = 0.04; syncope, p = 0.0099; thromboembolism, p = 0.03; NYHA class IV, p = 0.04). Postoperatively, the reduction in absolute LVMM (from 297.1 +/- 52.6 to 190.1 +/- 57.1 g versus 214.4 +/- 55.7 to 143.8 +/- 40.0 g; pT = 0.0000001) and indexed LVMM (from 156.0 +/- 31.7 to 99.3 +/- 28.4 g/m2 versus 118.7 +/- 28.3 to 79.3 +/- 20.6 g/m; pT = 0.0000001) over time was more significant in AR patients, but never reached normal values. Enforced ACE inhibitor medication resulted in significantly higher postoperative indexed LVMM differences in homozygote DD patients compared to AR patients with II/ID alleles of ACE 16 ins/del polymorphism. CONCLUSION: AR patients showed a statistically significant decrease in absolute/indexed LVMM during follow up, but never achieved LV mass recovery compared to standard values or to values in patients undergoing aortic valve replacement for AS. The benefits of ACE inhibitors were observed among AR patients with homozygote DD alleles of ACE 16 ins/del polymorphism.

25 years of cardiac CT imaging: past, present, and future.

PURPOSE: A brief summary of past, present, and future of cardiac CT is given. PAST: As long as the CT exposure time was in a range between 1 and 5 s, it was only possible to image cardiac morphology. At that time, we have learned the diagnostic criteria of transverse cardiac imaging especially in the field of pericardial diseases. Diagnostic criteria of constrictive pericarditis were developed which were superior to all other imaging modalities as it became possible to image the complete cardiac structures and the organs of the chest simultaneously without overlap and without any anatomic or patient limitation and observer-independent. A new concept of approach and therapy of this disease was developed, and in those institutions where this method was applied, the mortality from pericardiectomy could be essentially reduced and the surgical outcome results improved. PRESENT: The presence is characterized by an increase in functional imaging as there is a continuous reduction of the exposure time using the advanced multi-slice and multi-detector and electron-beam CT technology which is reflected by the integration of these methods in the daily evaluation of coronary heart disease. Coronary atherosclerosis, coronary arteries, functional parameters, and myocardial perfusion can be evaluated qualitatively and quantitatively. FUTURE: Technically, in the future further shortening of the exposure time and the introduction of flat detectors for real-time volume imaging may be expected with changes of diagnostic and therapeutic algorithms.