Epicardial Space: Comprehensive Anatomy and Spectrum of Disease.

The epicardial space (ES) is the anatomic region located between the myocardium and the pericardium. This space includes the visceral pericardium and the epicardial fat that contains the epicardial coronary arteries, cardiac veins, lymphatic channels, and nerves. The epicardial fat represents the main component of the ES. This fat deposit has been a focus of research in recent years owing to its properties and relationship with coronary gossypiboma plaque and atrial fibrillation. Although this region is sometimes forgotten, a broad spectrum of lesions can be found in the ES and can be divided into neoplastic and nonneoplastic categories. Epicardial neoplastic lesions include lipoma, paraganglioma, metastases, angiosarcoma, and lymphoma. Epicardial nonneoplastic lesions encompass inflammatory infiltrative disorders, such as immunoglobulin G4-related disease and Erdheim-Chester disease, along with hydatidosis, abscesses, coronary abnormalities, pseudoaneurysms, hematoma, lipomatosis, and gossypiboma. Initial imaging of epicardial lesions may be performed with echocardiography, but CT and cardiac MRI are the best imaging modalities to help characterize epicardial lesions. Due to the nonspecific onset of signs and symptoms, the clinical history of a patient can play a crucial role in the diagnosis. A history of malignancy, multisystem diseases, prior trauma, myocardial infarction, or cardiac surgery can help narrow the differential diagnosis. The diagnostic approach to epicardial lesions should be made on the basis of the specific location, characteristic imaging features, and clinical background. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Imaging of chronic thromboembolic pulmonary hypertension before, during and after balloon pulmonary angioplasty.

Balloon pulmonary angioplasty (BPA) has recently been elevated as a class I recommendation for the treatment of inoperable or residual chronic thromboembolic pulmonary hypertension (CTEPH). Proper patient selection, procedural safety, and post-procedural evaluation are crucial in the management of these patients, with imaging work-up playing a pivotal role. Understanding the diagnostic and therapeutic imaging algorithms of CTEPH, the imaging features of patients amenable to BPA, all imaging findings observed during and immediately after the procedure and the changes observed during the follow-up is crucial for all interventional radiologists involved in the care of patients with CTEPH. This article illustrates the imaging work-up of patients with CTEPH amenable to BPA, the imaging findings observed before, during and after BPA, and provides a detailed description of all imaging modalities available for CTEPH evaluation.

MRI Investigation of the Differential Impact of Left Ventricular Ejection Fraction After Myocardial Infarction in Elderly vs. Nonelderly Patients to Predict Readmission for Heart Failure.

BACKGROUND: Patients with ST-segment elevation myocardial infarction (STEMI), especially elderly individuals, have an increased risk of readmission for acute heart failure (AHF). PURPOSE: To study the impact of left ventricular ejection fraction (LVEF) by MRI to predict AHF in elderly (>70 years) and nonelderly patients after STEMI. STUDY TYPE: Prospective. POPULATION: Multicenter registry of 759 reperfused STEMI patients (23.3% elderly). FIELD STRENGTH/SEQUENCE: 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. ASSESSMENT: One-week MRI-derived LVEF (%) was quantified. Sequential MRI data were recorded in 579 patients. Patients were categorized according to their MRI-derived LVEF as preserved (p-LVEF, ≥50%), mildly reduced (mr-LVEF, 41%-49%), or reduced (r-LVEF, ≤40%). Median follow-up was 5 [2.33-7.54] years. STATISTICAL TESTS: Univariable (Student's t, Mann-Whitney U, chi-square, and Fisher's exact tests) and multivariable (Cox proportional hazard regression) comparisons and continuous-time multistate Markov model to analyze transitions between LVEF categories and to AHF. Hazard ratios (HR) with 95% confidence intervals (CIs) were computed. P < 0.05 was considered statistically significant. RESULTS: Over the follow-up period, 79 (10.4%) patients presented AHF. MRI-LVEF was the most robust predictor in nonelderly (HR 0.94 [0.91-0.98]) and elderly patients (HR 0.94 [0.91-0.97]). Elderly patients had an increased AHF risk across the LVEF spectrum. An excess of risk (compared to p-LVEF) was noted in patients with r-LVEF both in nonelderly (HR 11.25 [5.67-22.32]) and elderly patients (HR 7.55 [3.29-17.34]). However, the mr-LVEF category was associated with increased AHF risk only in elderly patients (HR 3.66 [1.54-8.68]). Less transitions to higher LVEF states (n = 19, 30.2% vs. n = 98, 53%) and more transitions to AHF state (n = 34, 53.9% vs. n = 45, 24.3%) were observed in elderly than nonelderly patients. DATA CONCLUSION: MRI-derived p-LVEF confers a favorable prognosis and r-LVEF identifies individuals at the highest risk of AHF in both elderly and nonelderly patients. Nevertheless, an excess of risk was also found in the mr-LVEF category in the elderly group. EVIDENCE LEVEL: 2. TECHNICAL EFFICACY: Stage 2.

Functional Tricuspid Regurgitation: Behind the Scenes of a Long-Time Neglected Disease.

Severe tricuspid valve regurgitation has been for a long time a neglected valve disease, which has only recently attracted an increasing interest due to the notable negative impact on the prognosis of patients with cardiovascular disease. It is estimated that around 90% of tricuspid regurgitation is diagnosed as "functional" and mostly secondary to a primary left-sided heart disease and, therefore, has been usually interpreted as a benign condition that did not require a surgical management. Nevertheless, the persistence of severe tricuspid regurgitation after left-sided surgical correction of a valve disease, particularly mitral valve surgery, has been associated to adverse outcomes, worsening of the quality of life, and a significant increase in mortality rate. Similar results have been found when the impact of isolated severe tricuspid regurgitation has been studied. Current knowledge is shifting the "functional" categorization toward a more complex and detailed pathophysiological classification, identifying various phenotypes with completely different etiology, natural history and, potentially, an invasive management. The aim of this review is to offer a comprehensive guide for clinicians and surgeons with a systematic description of "functional" tricuspid regurgitation subtypes, an analysis centered on the effectiveness of existing surgical techniques and a focus on the emergent percutaneous procedures. This latter may be an attractive alternative to a standard surgical approach in patients with high-operative risk or isolated tricuspid regurgitation.

Cardiac and Pulmonary Vascular Remodeling in Endurance Open Water Swimmers Assessed by Cardiac Magnetic Resonance: Impact of Sex and Sport Discipline.

Background: The cardiac response to endurance exercise has been studied previously, and recent reports have described the extension of this remodeling to the pulmonary vasculature. However, these reports have focused primarily on land-based sports and few data are available on exercise-induced cardio-pulmonary adaptation in swimming. Nor has the impact of sex on this exercise-induced cardio-pulmonary remodeling been studied in depth. The main aim of our study was to evaluate cardiac and pulmonary circulation remodeling in endurance swimmers. Among the secondary objectives, we evaluate the impact of sex and endurance sport discipline on this cardio-pulmonary remodeling promoted by exercise training. Methods:Resting cardiovascular magnetic resonance imaging was performed in 30 healthy well-trained endurance swimmers (83.3% male) and in 19 terrestrial endurance athletes (79% male) to assess biventricular dimensions and function. Pulmonary artery dimensions and flow as well as estimates of pulmonary vascular resistance (PVR) were also evaluated. Results:In relation to the reference parameters for the non-athletic population, male endurance swimmers had larger biventricular and pulmonary artery size (7.4 ± 1.0 vs. 5.9 ± 1.1 cm2, p < 0.001) with lower biventricular ejection fraction (EF) (left ventricular (LV) EF: 58 ± 4.4 vs. 67 ± 4.5 %, p < 0.001; right ventricular (RV) EF: 60 ± 4 vs. 66 ± 6 %, p < 0.001), LV end-diastolic volume (EDV): 106 ± 11 vs. 80 ± 9 ml/m2, p < 0.001; RV EDV: 101 ± 14 vs. 83 ± 12 ml/m2, p < 0.001). Significantly larger LV volume and lower LV EF were also observed in female swimmers (LV EF: 60 ± 5.3 vs. 67 ± 4.6 %, p = 0.003; LV EDV: 90 ± 17.6 vs. 75± 8.7 ml/m2, p = 0.002). Compared to terrestrial endurance athletes, swimmers showed increased LV indexed mass (75.0 ± 12.8 vs. 61.5 ± 10.0 g/m2, p < 0.001). The two groups of endurance athletes had similar pulmonary artery remodeling. Conclusions: Cardiac response to endurance swimming training implies an adaptation of both ventricular and pulmonary vasculature, as in the case of terrestrial endurance athletes. Cardio-pulmonary remodeling seems to be less extensive in female than in male swimmers.

Contrast-Enhanced Lung Ultrasound: A New Horizon / Ecografía pulmonar con contraste: un nuevo horizonte

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Assessment of myocardial deformation with CMR: a comparison with ultrasound speckle tracking.

OBJECTIVES: Myocardial deformation integrated with cardiac dimensions provides a comprehensive assessment of cardiac function, which has proven useful to differentiate cardiac pathology from physiological adaptation to situations such as chronic intensive training. Feature tracking (FT) can measure myocardial deformation from cardiac magnetic resonance (CMR) cine sequences; however, its accuracy is not yet fully validated. Our aim was to compare the accuracy and reproducibility of FT with speckle tracking echocardiography (STE) in highly trained endurance athletes. METHODS: Ninety-three endurance athletes (> 12-h training/week during the last 5 years, 52% male, 35 ± 5.1 years old) and 72 age-matched controls underwent resting CMR and transthoracic echocardiography to assess biventricular exercise-induced remodeling and biventricular global longitudinal strain (GLS) by CMR-FT and STE. RESULTS: Strain values were significantly lower when assessed by CMR-FT compared to STE (p < 0.001), with good reproducibility for the left ventricle (bias = 3.94%, limit of agreement [LOA] = ± 4.27 %) but wider variability for right ventricle strain. Strain values by both techniques proportionally decreased with increasing ventricular volumes, potentially depicting the functional biventricular reserve that characterizes athletes' hearts. CONCLUSIONS: Biventricular longitudinal strain values were lower when assessed by FT as compared to STE. Both methods were statistically comparable when measuring LV strain but not RV strain. These differences might be justified by the lower in-plane spatial and temporal resolution of FT, which is particularly relevant for the complex anatomy of the RV. KEY POINTS: • Strain values were significantly lower when assessed by FT as compared to STE, which was expected due to the lower in-plane spatial and temporal resolution of FT versus STE. • Both methods were statistically comparable when measuring LV strain but not for RV strain analysis. • Characterizing the normal ranges and reproducibility of strain metrics by FT is an important step toward its clinical applicability, since it can be assessed offline and applied to routinely acquired cine CMR images.

Bariatric Surgery-Induced Changes in Intima-Media Thickness and Cardiovascular Risk Factors in Class 3 Obesity: A 3-Year Follow-Up Study.

OBJECTIVE: The impact of weight loss induced by bariatric surgery (BS) and nonsurgical approaches on cardiovascular risk factors (CVRFs) has not been fully elucidated. We assessed the effects of BS and a nonsurgical approach on carotid intima-media thickness (CIMT) and CVRFs in participants with class 3 obesity. METHODS: A total of 87 participants with obesity (59 women; 46 [37-52] years old; BMI, 43 [40-47]) and 75 controls were recruited; 21 (25%) participants with obesity underwent BS. BMI, blood pressure, cholesterol, triglycerides, fasting plasma glucose, C-reactive protein, CIMT, and Framingham Risk Score were measured at baseline and at 3-year follow-up. Independent factors for reduction in CIMT were analyzed. The literature on the effects of BS and CIMT was reviewed. RESULTS: After BS, BMI decreased from 45.45 to 27.28 (P < 0.001), and mean CIMT decreased from 0.64 mm (0.56-0.75 mm) to 0.54 mm (0.46-0.65) mm (P < 0.012), equivalent to 0.005 mm/kg of weight lost. At 3-year follow-up, participants who had undergone BS had similar CIMT and CVRFs to the control group. No changes in CVRFs were seen related to the nonsurgical approach. BMI reduction after BS had the strongest independent association with decreased CIMT. CONCLUSIONS: Weight loss after BS decreases CIMT and CVRFs in middle-aged participants with class 3 obesity, resulting in CIMT similar to that observed in lean participants.

Duodenal tumors on cross-sectional imaging with emphasis on multidetector computed tomography: a pictorial review.

Duodenal tumours are uncommon, but they can cause significant morbidity and mortality. As stomach and colon are a more common site of gastrointestinal malignancies, radiologists sometimes neglect the duodenum. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can accurately locate and characterize mass-forming duodenal lesions, making them invaluable for the differential diagnosis and determining management strategies such as biopsy or surgery. Although conventional endoscopy continues to play an important role in the diagnosis of duodenal tumors, MDCT and MRI are very useful for evaluating the duodenal wall, extraduodenal space, and surrounding viscera, as well as the intraluminal content seen on endoscopy. This pictorial review aims to illustrate the most common benign and malignant mass-forming duodenal lesions and to focus on the imaging features that are most helpful in reaching the correct diagnosis.

Exercise-induced cardio-pulmonary remodelling in endurance athletes: Not only the heart adapts.

BACKGROUND: The cumulative effects of intensive endurance exercise may induce a broad spectrum of right ventricular remodelling. The mechanisms underlying these variable responses have been scarcely explored, but may involve differential pulmonary vasculature adaptation. Our aim was to evaluate right ventricular and pulmonary circulation in highly trained endurance athletes. METHODS: Ninety-three highly trained endurance athletes (>12 h training/week at least during the last five years; age: 36 ± 6 years; 52.7% male) and 72 age- and gender-matched controls underwent resting cardiovascular magnetic resonance imaging to assess cardiac dimensions and function, as well as pulmonary artery dimensions and flow. Pulmonary vascular resistance (PVR) was estimated based on left ventricular ejection fraction and pulmonary artery flow mean velocity. Resting and exercise Doppler echocardiography was also performed in athletes to estimate pulmonary artery pressure. RESULTS: Athletes showed larger biventricular and biatrial sizes, slightly reduced systolic biventricular function, increased pulmonary artery dimensions and reduced pulmonary artery flow velocity as compared with controls in both genders (p < 0.05), which resulted in significantly higher estimated PVR in athletes as compared with controls (2.4 ± 1.2 vs. 1.7 ± 1.1; p < 0.05). Substantially high estimated PVR values (>4.2 WU) were found in seven of the 93 (9.3%) athletes: those exhibiting an enlarged pulmonary artery (indexed area cm2/m2: 4.8 ± 0.6 vs. 3.9 ± 0.6, p < 0.05), a decreased pulmonary artery distensibility index (%: 43.0 ± 15.2 vs. 62.0 ± 17.4, p < 0.05) and a reduced right ventricular ejection fraction (%: 49.3 ± 4.5 vs. 53.6 ± 4.6, p < 0.05). CONCLUSIONS: Exercise-induced remodelling involves, besides the cardiac chambers, the pulmonary circulation and is associated with an increased estimated PVR. A small subset of athletes exhibited substantial increase of estimated PVR related to pronounced pulmonary circulation remodelling and reduced right ventricular systolic function.

The Chiari Network-Only an Embryonic Remnant or a Confusing Finding?

Chiari network is an embryonic remnant of valves of the sinus venosus, which can be observed in several locations in the right atrium. Although it is usually considered a normal anatomic variant, when associated with certain clinical conditions, the Chiari network may become a confusing finding, and a careful differential diagnosis is required. It should be differentiated from a tricuspid valve disruption, vegetation, thrombus, or tumoral mass. In this case report, we describe a singular case of endocarditis over a Chiari network in a seven-year-old boy that was successfully managed in a conservative fashion.

Macrovascular Networks on Contrast-Enhanced Magnetic Resonance Imaging Improves Survival Prediction in Newly Diagnosed Glioblastoma.

A higher degree of angiogenesis is associated with shortened survival in glioblastoma. Feasible morphometric parameters for analyzing vascular networks in brain tumors in clinical practice are lacking. We investigated whether the macrovascular network classified by the number of vessel-like structures (nVS) visible on three-dimensional T1-weighted contrast⁻enhanced (3D-T1CE) magnetic resonance imaging (MRI) could improve survival prediction models for newly diagnosed glioblastoma based on clinical and other imaging features. Ninety-seven consecutive patients (62 men; mean age, 58 ± 15 years) with histologically proven glioblastoma underwent 1.5T-MRI, including anatomical, diffusion-weighted, dynamic susceptibility contrast perfusion, and 3D-T1CE sequences after 0.1 mmol/kg gadobutrol. We assessed nVS related to the tumor on 1-mm isovoxel 3D-T1CE images, and relative cerebral blood volume, relative cerebral flow volume (rCBF), delay mean time, and apparent diffusion coefficient in volumes of interest for contrast-enhancing lesion (CEL), non-CEL, and contralateral normal-appearing white matter. We also assessed Visually Accessible Rembrandt Images scoring system features. We used ROC curves to determine the cutoff for nVS and univariate and multivariate cox proportional hazards regression for overall survival. Prognostic factors were evaluated by Kaplan-Meier survival and ROC analyses. Lesions with nVS > 5 were classified as having highly developed macrovascular network; 58 (60.4%) tumors had highly developed macrovascular network. Patients with highly developed macrovascular network were older, had higher volumeCEL, increased rCBFCEL, and poor survival; nVS correlated negatively with survival (r = -0.286; p = 0.008). On multivariate analysis, standard treatment, age at diagnosis, and macrovascular network best predicted survival at 1 year (AUC 0.901, 83.3% sensitivity, 93.3% specificity, 96.2% PPV, 73.7% NPV). Contrast-enhanced MRI macrovascular network improves survival prediction in newly diagnosed glioblastoma.