Early detection of cancer therapy cardiotoxicity by radionuclide angiography: An update.

Cancer therapy-induced cardiotoxicity is an emerging clinical and healthcare issue. Myocardial dysfunction and heart failure are mostly responsible for increased cardiovascular mortality in cancer disease survivors. Several imaging surveillance techniques have been proposed for early diagnosis of cancer therapy-induced cardiac dysfunction. Our aim was to provide an update of radionuclide angiography applications in this field. Radionuclide angiography is widely used to assess left ventricular ejection fraction (LVEF) throughout cancer treatment, especially in patients with limited acoustic window. Additional prognostic data may be provided by phase analysis and diastolic function evaluation. Low LVEF and high approximate entropy at baseline seem to be predictors for cancer therapy-induced cardiac dysfunction. A decrease in peak filling rate and/or an increase in time to peak filling rate may be observed in patients undergoing anthracycline and/or trastuzumab administration. Diastolic function impairment may precede or not LVEF decrease. In conclusion, recent studies have provided novel insights into the possible role of radionuclide angiography in the early detection of cancer therapy cardiotoxicity. While interpreting the results of a radionuclide angiography examination, an integrated approach combining the evaluation of LVEF, LV diastolic function, and phase analysis may be useful to improve risk stratification of cancer patients treated with cardiotoxic agents.

Ten-year follow-up of cardiac resynchronization therapy patients with non-ischemic dilated cardiomyopathy assessed by radionuclide angiography: a single-center cohort study.

PURPOSE: Relatively few data are available on long-term survival and incidence of ventricular arrhythmias in cardiac resynchronization therapy (CRT) patients. We investigated long-term outcomes of CRT patients with non-ischemic dilated cardiomyopathy stratified as responders or non-responders according to radionuclide angiography. METHODS: Fifty patients with non-ischemic dilated cardiomyopathy undergoing CRT were assessed by equilibrium Tc99 radionuclide angiography with bicycle exercise at baseline and after 3 months. Intra- and interventricular dyssynchrony were derived by Fourier phase analysis. Patient clinical outcome was assessed after 10 years. RESULTS: At 3 months, 50% of patients were identified as CRT responders according to an increase in LV ejection fraction ≥ 5%. During a follow-up of 109 ± 48 months, 30% of patients died and 6% underwent heart transplantation. Age and history of paroxysmal atrial fibrillation were found to be predictors of all-cause mortality. CRT responders showed lower risk of death from cardiac causes than non-responders. At follow-up, 38% of patients presented at least one episode of sustained ventricular tachycardia, with a similar percentage between responders and non-responders. CONCLUSION: At long-term follow-up, non-ischemic CRT recipients identified as responders by radionuclide angiography were found to be at lower risk of worsening heart failure death than non-responders. Long-term risk for sustained ventricular arrhythmia was similar between CRT responders and non-responders.

Equilibrium radionuclide angiography: Intra- and inter-observer repeatability and reproducibility in the assessment of cardiac systolic and diastolic function.

BACKGROUND: This study aimed to assess intra- and inter-observer agreement in assessing the systolic and diastolic function with equilibrium radionuclide angiography (ERNA). MATERIALS AND METHODS: Thirty-two adults underwent baseline and repeat ERNA. An experienced and a trainee operator analyzed the data by assigning regions of interest manually, fully automatically, and semi-automatically. The Bland-Altman statistic (mean ± 1.96 standard deviations of the differences) was used to assess the repeatability (two different assessments of a single acquisition) and reproducibility (assessments of two different acquisitions). RESULTS: Using the semi-automated technique the intraobserver repeatability and reproducibility of left ventricular ejection fraction for the experienced physician were - 0.1 ± 3.7 and 0.0 ± 3.8 and for the trainee 2.2 ± 10.6 and 1.9 ± 8.4, respectively. The inter-observer repeatability and reproducibility were - 1.8 ± 6.4 and 0.4 ± 9.0, respectively. Among the parameters of diastolic function, the intraobserver repeatability and reproducibility of the peak filling rate for the experienced physician were - 0.0 ± 1.1 and - 0.1 ± 1.1 and for the trainee 0.2 ± 3.5 and 0.4 ± 3.7, respectively. The inter-observer repeatability and reproducibility were 0.3 ± 1.5 and 0.5 ± 4.0, respectively. Similar was the pattern for the other diastolic indices. In all cases the limits of agreement varied according to the quantification approach. CONCLUSION: A good repeatability but a moderate reproducibility was found in the assessment of the LVEF. Less good were the findings in the assessment of diastolic function.

Effects of nucleo(s)tide analogs therapy on chronic hepatitis B as evaluated by hepatosplenic radionuclide angiography.

OBJECTIVES: Hepatosplenic radionuclide angiography is a relatively noninvasive method for evaluating hepatic portal perfusion. We used hepatosplenic radionuclide angiography to assess the effects of nucleo(s)tide analogs therapy on patients with chronic hepatitis B (CHB). PATIENTS AND METHODS: A retrospective analysis was performed on patients who underwent hepatosplenic radionuclide angiography from January 2012 to May 2017 at the First Affiliated Hospital, College of Medicine, Zhejiang University. The correlations between the results of routine laboratory tests and hepatic perfusion index (HPI) were evaluated. The Wilcoxon signed-rank test and one-way ANOVA of repeated measures were used to compare the HPIs of patients who received nucleo(s)tide analogs therapy. RESULTS: There is a positive correlation between HPI and cholinesterase and serum albumin (ALB) and a negative correlation between HPI and aspartate aminotransferase-to-platelet ratio index and bilirubin (TBiL). An improvement in HPI was observed in patients with an initial HPI <61% after nucleo(s)tide analogs therapy. CONCLUSIONS: Hepatosplenic radionuclide angiography can reflect the functional reserve of the liver and monitor liver fibrosis indirectly. It can also comprehensively assess the effects of antiviral therapy on patients with CHB, and antiviral therapy is critical for the treatment of hepatitis.

Necessity of routine cardiac evaluation in patients receiving pegylated liposomal doxorubicin for gynecologic cancer.

OBJECTIVE: Pegylated liposomal doxorubicin (PLD) has similar reported clinical efficacy compared with conventional doxorubicin with less cardiotoxicity. The manufacturer of PLD advises that cardiac function should be evaluated with endomyocardial biopsy, echocardiography or multigated radionucleotide scan (MUGA) pre-treatment and during therapy. This study was designed to assess the necessity of pre-treatment cardiac evaluation in patients receiving PLD. METHODS: After IRB approval, a retrospective study of all women with gynecologic cancer who received PLD from 2006 to 2018 was performed. Demographic information, treatment records, cardiac risk factors, and cardiac surveillance testing were examined. Wilcoxon signed rank sum test and logistic regression were used to evaluate the association of cumulative PLD exposure with cardiotoxicity. RESULTS: A total of 235 patients received PLD for gynecologic cancer. Patients received a median of 3 cycles of PLD with a cumulative dosage of 237 mg over a median follow-up time of 24 months. Sixteen patients in the cohort (7%) had no cardiac surveillance at all. Of the remaining patients who underwent cardiac testing, 183 (84%) received MUGA scans and 36 (16%) had echocardiography. Of the 56 patients who had both pre- and post-treatment cardiac testing, there was no significant difference in median ejection fraction (p = 0.17). Three patients developed PLD-associated cardiac toxicity but only one patient had severe manifestations requiring discontinuation of PLD therapy. CONCLUSIONS: Routine cardiac testing before, during or after treatment with PLD may be unnecessary. Cardiac testing may be more appropriate for individual patients for whom the clinical suspicion of PLD-related cardiac toxicity is high.

Left ventricular ejection fraction determined with the simulation of a very low-dose CZT-SPECT protocol and an additional count-calibration on planar radionuclide angiographic data.

PURPOSE: To determine whether the left ventricular ejection fractions (EFs), measured on a high-sensitivity CZT single photon emission computed tomography (SPECT)-camera with a 70% reduction in recording times and a prevention of EF overestimation through an additional count-calibration, are concordant with reference EF from planar radionuclide angiography (2D-RNA). METHODS: An additional 10-minute CZT-SPECT recording was performed in patients referred to 2D-RNA for cardiomyopathy (n = 23) or chemotherapy monitoring (n = 50) with an in vivo red blood cell labeling with 850 MBq [Formula: see text]. The EF, obtained from CZT-SPECT with 100% (SPECT100) or 30% (SPECT30) projection times and with a SPECT-count calibration on the 2D-RNA counts of corresponding cavity volumes, were compared to EF from 2D-RNA. RESULTS: Strong and equivalent relationships were documented between the EF from 2D-RNA and the calibrated EF from SPECT100 (y = 0.89x + 6.62; R2 = 0.87) and SPECT30 (y = 0.87x + 8.40; R2 = 0.85), and the mean EF from SPECT100 (54% ± 15%) and SPECT30 (53% ± 16%) were close to that from 2D-RNA (55% ± 15%). However, upward shifts in these mean values were documented in the absence of count calibration for both SPECT100 (60% ± 18%) and SPECT30 (60% ± 18%). CONCLUSION: Left ventricular EF may be determined on a high-sensitivity CZT-camera, a 70% reduction in injected activities, and an additional count-calibration for further enhancing the concordance with 2D-RNA values.

Effects of cardiac resynchronization therapy on right ventricular function during rest and exercise, as assessed by radionuclide angiography, and on NT-proBNP levels.

AIM: We carried out this study to investigate mid-term effects of cardiac resynchronization therapy (CRT) on right ventricular (RV) function and neurohormonal response, expressed by N-terminal pro-brain natriuretic peptide (NT-proBNP), in heart failure patients stratified by baseline RV ejection fraction (RVEF). METHODS AND RESULTS: Thirty-six patients with nonischemic dilated cardiomyopathy underwent technetium-99m radionuclide angiography with bicycle exercise immediately after CRT implantation (during spontaneous rhythm and after CRT activation) and 3 months later. Plasma NT proBNP was assessed before implantation and after 3 months. At baseline, RVEF was impaired (≤35%) in 14 patients, preserved (>35%) in 22. At 3 months, RVEF improved during rest and exercise (P = .02) in patients with impaired RV function, while remaining unchanged in patients with preserved RV function. Rest and exercise RV dyssynchrony decreased in both groups at follow-up (P < .05). A similar mid-term improvement in left ventricular (LV) function and NT-proBNP was observed in patients with impaired and preserved RVEF. In the former, the decrease in NT-proBNP correlated with the improvements both in LV and RV dyssynchrony and functions. CONCLUSION: CRT may improve RV performance, during rest and exercise, and neurohormonal response in heart failure patients with nonischemic dilated cardiomyopathy and baseline RV dysfunction. RV dysfunction should not be considered per se a primary criterion for excluding candidacy to CRT.

A practical background correction method for an immediately repeated first-pass radionuclide angiography.

BACKGROUND: A satisfactory bolus injection is essential for a successful first-pass radionuclide angiography (FPRNA). Rescheduling the FPRNA study is usually needed due to high background interference caused by an unsatisfactory bolus injection. We developed a protocol to correct the pre-existing background activity subsequent to immediately repeating the study. METHODS: Seventy-four consecutive patients who had their bone scan and FPRNA scheduled on the same day were included for analysis. The initial 51 cases constituted the "validation-only" group. In the other 23 cases, the "validation plus clearance constants" group, a 5-min dynamic acquisition was performed during the 5-min equilibrium to obtain the background clearance curve and the clearance constants. For all included 74 cases ejection fraction (EF) analysis was proceeded using the images from the first injection, second injection, and second injection with the corrected background to yield EF1, EF2, and EF2', respectively. EF2 and EF2' were then compared to the ejection fraction without background interference, the EF1. RESULTS: For the LV, the mean difference between the EF1 and the uncorrected EF2 (|LVEF1-LVEF2| in mean ± SD) was 3.1 ± 2.0% and the difference between the EF1 and the corrected EF2' (|LVEF1-LVEF2'|) was 1.6 ± 2.1%, while the mean differences for RV are 2.2 ± 1.9% and 1.8 ± 1.8%, respectively. A significant difference (p < 0.05) was observed between the uncorrected and the corrected data for both the LV and RV. CONCLUSION: In FPRNA, when a bolus injection is immediately readministered, both LVEF and RVEF can be underestimated. With our correction method, the results are superior to those without correction.

2D-speckle tracking right ventricular strain to assess right ventricular systolic function in systolic heart failure. Analysis of the right ventricular free and posterolateral walls.

BACKGROUND: Right ventricular (RV) systolic function is a powerful prognostic factor in patients with systolic heart failure. The accurate estimation of RV function remains difficult. The aim of the study was to determine the diagnostic accuracy of 2D-speckle tracking RV strain in patients with systolic heart failure, analyzing both free and posterolateral walls. METHODS: Seventy-six patients with dilated cardiopathy (left ventricular end-diastolic volume≥75ml/m2) and left ventricular ejection fraction≤45% had an analysis of the RV strain. Feasibility, reproducibility and diagnostic accuracy of RV strain were analyzed and compared to other echocardiographic parameters of RV function. RV dysfunction was defined as a RV ejection fraction≤40% measured by radionuclide angiography. RESULTS: RV strain feasibility was 93.9% for the free-wall and 79.8% for the posterolateral wall. RV strain reproducibility was good (intra-observer and inter-observer bias and limits of agreement of 0.16±1.2% [-2.2-2.5] and 0.84±2.4 [-5.5-3.8], respectively). Patients with left heart failure have a RV systolic dysfunction that can be unmasked by advanced echocardiographic imaging: mean RV strain was -21±5.7% in patients without RV dysfunction and -15.8±5.1% in patients with RV dysfunction (p=0.0001). Mean RV strain showed the highest diagnostic accuracy to predict depressed RVEF (area under the curve (AUC) 0.75) with moderate sensitivity (60.5%) but high specificity (87.5%) using a cutoff value of -16%. CONCLUSIONS: RV strain seems to be a promising and more efficient measure than previous RV echocardiographic parameters for the diagnosis of RV systolic dysfunction.

Harmonic subtraction for evaluating right ventricle ejection fraction from planar equilibrium radionuclide angiography.

We report an initial investigation of a subtraction-based method to estimate right ventricle ejection fraction (RVEF) from ECG-gated planar equilibrium radionuclide angiography (ERNA) data. Twenty-six consecutive patients referred for scintigraphic evaluation of cardiac function prior to chemotherapy had ECG-gated first-pass (FP) imaging and ERNA imaging performed following the same radiotracer injection. RVEF was computed from FP images (RVEFFP) and separately from ERNA images (RVEFERNA). Standard methods for computing ejection fractions were used to obtain RVEFFP values. RVEFERNA values were obtained using harmonic subtraction of the left ventricular contribution from a biventricular region of interest contoured on the equilibrium images acquired in the shallow right anterior oblique projection. Clinically acquired chest CT data were used to derive information regarding the relative position of the left and right ventricle and about the presence of pulmonary artery enlargement. Computation of RVEFERNA was successful for each of the 26 patients. Computation of RVEFFP failed for four patients. For the 22 patients for which RVEF was computed using both methods, the average RVEFFP was 49% and the average RVEFERNA was 51%, with coefficients of variation of 11 and 7.5%, respectively. Low RVEFERNA values were associated with pulmonary artery dilation. Estimation of RVEFERNA, using a harmonic subtraction-based method of computation is clinically feasible and accurate in the patient population studied. The results support further investigation in patients with frank heart failure.

Comparison of echocardiographic parameters to assess right ventricular function in pulmonary hypertension.

Although measurement of right ventricular ejection fraction (RVEF) may be relevant for evaluation of therapeutic efficacy and/or prognosis in patients with pulmonary hypertension, RVEF obtained by echocardiography has limited accuracy. In contrast, radionuclide and/or magnetic resonance imaging can measure RVEF more reliably. In this study, we investigated the relationship between RVEF measured by radionuclide angiography and the echocardiographic parameters that are recommended by the American Society of Echocardiography as representative of right heart function. There were 23 study participants with pulmonary hypertension who underwent radionuclide angiography and 2-dimensional and Doppler echocardiography (n = 30 measurements). RVEF measured by radionuclide angiography correlated with right ventricular Tei index (RV Tei index) measured by Doppler echocardiography (r = -0.601, P < 0.0005). Receiver operating characteristic curve analysis showed that an RV Tei index cut-off value of 0.371 was the best of predictor of RVEF ≤35% (area under the curve = 0.768, sensitivity = 0.857, selectivity = 0.667). Multiple regression analysis showed that RVEF was correlated with the RV Tei index, and this association was independent of other echocardiographic right ventricular function parameters (r = -0.644, P < 0.005). The RV Tei index measured by Doppler echocardiography may be an acceptable surrogate marker of RVEF in patients with pulmonary hypertension.

Rotura aneurismática aguda en paciente con HSA grave objetivada en AngioTC craneal / Acute aneurysmal rupture in a severe SAH patient seen on head CT angiography scan

No disponible

Quistes renales y aneurismas de aorta de gran tamaño / Renal cysts and large aortic aneurysms

INTRODUCCIÓN: Los quistes renales se han relacionado con una mayor presencia y un mayor diámetro de aneurismas de aorta abdominal (AAA). OBJETIVO: Evaluar la proporción de pacientes con AAA y con quiste simple renal (QSR) en nuestra población y valorar su relación con el diámetro aneurismático. MATERIAL Y MÉTODOS: Realizamos un estudio transversal de pacientes consecutivos diagnosticados de AAA infrarrenal con tomografía axial computarizada con contraste entre 2013 y 2016 en nuestro centro. Registramos sus datos demográficos, factores de riesgo para el desarrollo y el crecimiento del AAA y la presencia de QSR. Se realizó una estadística descriptiva con medidas de tendencia central, dispersión y un análisis de la relación del diámetro aneurismático con la presencia de QSR y su presencia uni- o bilateral. RESULTADOS: Incluimos a 135 pacientes con edad media de 74 años (DE: 11,3). El 54,8% (n=68) tenían QSR, de los cuales el 50,7% (n=35) eran bilaterales. El diámetro medio de los AAA de los pacientes sin QSR (n=67) fue de 59,2mm (DE: 12,3) en contraste con el diámetro aneurismático medio de los pacientes con QSR (n=68) que fue de 65,2mm (DE: 15,3) (p = 0,36). Tampoco se observaron diferencias significativas en el diámetro máximo de los AAA de los pacientes con QSR unilaterales (n=33) respecto a los pacientes con AAA y QSR bilaterales (n=35) (53,5 versus 59,1mm; p = 0,16). CONCLUSIÓN: En nuestra serie, no se encontró relación significativa entre presencia de QSR, bilateralidad y tamaño de los AAA

INTRODUCTION: Renal cysts have been associated with an increase in the presence abdominal aortic aneurysm (AAA) and also with a larger aneurysmal sac diameter. OBJECTIVE: To study the proportion of patients with AAA and simple renal cyst (SRC) in our population and study their relationship with the aneurysmal diameter. MATERIAL AND METHODS: A cross-sectional study was conducted on consecutive patients diagnosed with infrarenal AAA using contrast computed tomography between 2013 and 2016 in our centre. Information was collected on the demographics of participants, including risk factors associated with AAA development, growth rates of AAA, and the presence of renal cysts. Descriptive statistics were performed with measurements of central tendency and dispersion, and an analysis of the relationship between aneurysmal diameter and the presence of uni- or bilateral renal cysts. RESULTS: A total of 135 patients were included, with a mean age of 74 years (SD 11.3). Renal cysts were present in 54.8% (n=68) of cases, with 50.7% (n=35) of these being bilateral SRC. The mean diameter of the AAA in patients (n=67) without a SRC was 59.2mm (SD 12.3), as opposed to a mean AAA diameter of 65.2mm (SD 15.3) in patients (n=68) with a SRC (P=.36). No significant differences were observed in the maximum diameter of the AAA in patients (n=33) with a unilateral SRC compared to patients with a bilateral SRC (n=35) (53.5 versus 59.1mm; P=.16). CONCLUSION: No significant relationship was found in this series between the presence of an SRC, bilateralism, and the size of the AAA

Catorce años de experiencia con injertos a la arteria pedia / Fourteen years of experience with pedal bypasses

OBJETIVO: Revisar nuestros resultados en injertos a la arteria pedia, realizados por isquemia crítica, en un periodo de 14 años. MÉTODOS: Se realizó un análisis retrospectivo de los injertos realizados a la arteria pedia en nuestro centro entre agosto de 2000 y enero de 2014. Registramos las siguientes variables clínicas: edad, sexo, factores de riesgo cardiovascular y comorbilidad renal. Analizamos, como variables resultado: permeabilidades primaria, asistida y secundaria, tasa libre de amputación y mortalidad a 1 y 3 años. Realizamos un análisis estadístico uni y multivariante utilizando los tests no paramétricos de Mann-Whitney y Kruskal-Wallis. RESULTADOS: Se analizaron 59 injertos en 49 pacientes. La edad media fue de 72 años (rango 41-90). El 59% (n = 35) eran varones, el 83% (n=49) eran diabéticos y el 20% (n = 12) estaban en diálisis. La indicación fue en todos los casos isquemia crítica. Los 59 injertos utilizados incluyeron 49%(n = 28) venas safenas invertidas, 29% (n = 17) venas safenas in situ, 12% (n = 7) venas de brazo y 12% (n = 7) injertos compuestos. Las arterias donantes fueron: femoral común (9%, n = 5), femoral superficial (27%, n = 16), 1.ª porción de poplítea (3%, n = 2), 3.ª porción de poplítea (35%, n = 21), arteria tibial anterior (5%, n = 3) e injerto previo (20%, n = 12). La mortalidad perioperatoria fue del 3% (n = 2). El seguimiento medio fue de 27 meses (rango 1- 96 meses). Las permeabilidades primaria, asistida, secundaria y el salvamento de la extremidad al año fueron del 53, del 73, del 80 y del 82%, respectivamente. A los 3 años, la permeabilidad secundaria fue del 79% y la supervivencia libre de amputación, del 78%. CONCLUSIÓN: Los injertos a la arteria pedia son una opción válida en isquemia crítica, con buenas tasas de permeabilidad y salvamento de extremidad a uno y 3 años

OBJECTIVE: To review our results in pedal bypasses performed in critical ischaemic limbs during a 14 year period. METHODS: A retrospective study was conducted to evaluate pedal bypasses that were performed in our centre between August 2000 and January 2014. A record was made of the following clinical variables: age, sex, cardiovascular risk factors, and renal comorbidity. An analysis was made of the primary, assisted and secondary patency, amputation-free survival mortality at 1 and 3 years. A uni- and multi-variate statistical analysis was performed, using Mann-Whitney and Kruskal- Wallis non-parametric tests. RESULTS: The analysis included 49 bypasses on 59 patients. The mean age was 72 years (range 41-90). Fifty-nine percent of them were male patients (n = 35), 83% (n = 49) diabetics, and 20% (n = 12) were in a haemodialysis program. The surgical indication was critical limb ischaemia in all cases. The grafts included: 49% (n = 28) reversed saphenous vein, 29% (n = 17) in situ, 12% (n = 7) arm veins, and 12% (n = 7) composite grafts. The inflow arteries were as follows: common femoral artery (9%, n = 5), superficial femoral (27%, n = 16), first popliteal portion (3%, n = 2), third popliteal portion (36%, n = 21), anterior tibial artery (5%, n = 3), and previous graft (20%, n = 12). Peri-operative mortality was 3% (n = 2). The follow up period was 27 months (range from 1 to 96 months). Primary, assisted and secondary patency, and limb salvage were 53%, 73%, 80%, and 82%, respectively, at 1 year. At 3 years, secondary patency was 79%, and amputation free survival was 78%. CONCLUSION: Pedal bypasses are a valid option for critical limb ischaemia with good patency rates and limb salvage at one and three years

Fístulas arteriovenosas de los troncos supraaórticos / Arteriovenous fistulas of supra-aortic trunks

No disponible