MR imaging assessment of myocardial edema with T2 mapping.

Cardiac magnetic resonance (CMR) provides a high signal-to-noise ratio, high spatial and temporal resolutions, as well as a delayed-enhancement sequence and is therefore considered a reference technique in the field of cardiac imaging. However, currently available sequences are not adequate to assess some pathologic conditions, such as myocardial edema. T2 mapping sequences generate parametric images that are based on the transverse relaxation time (T2) for each voxel. In case of edema, the T2 relaxation time is longer. This review summarizes current knowledge on CMR T2 mapping for assessing myocardial edema.

[Emergent transcatheter aortic valve implantation in a patient with bicuspid aortic valve stenosis in cardiogenic shock]. / Choc cardiogénique sur bicuspidie aortique sténosante traité par remplacement valvulaire aortique percutané en urgence.

Transcatheter aortic valve implantation is a therapeutic option for high-risk patients with severe aortic valve stenosis and with cardiac symptoms. This procedure requires the preliminary evaluation by a "heart team" and presents some contraindications. We report the case of a 58-year-old man with severe bicuspid aortic valve stenosis and cardiogenic shock. In spite of contraindications and because of the failure of balloon aortic valvuloplasty, transcatheter aortic valve implantation was performed in emergency.

[Mechanisms of delayed myocardial enhancement and value of MR and CT contrast materials in the evaluation of myocardial viability]. / Mécanismes du rehaussement tardif myocardique et apport des produits de contraste en IRM et scanner dans le diagnostic de viabilité myocardique.

The purpose of this article is to present a brief theoretical review of the models characterizing delayed myocardial enhancement applicable to both MR and CT imaging, review the different characteristics of commercially available gadolinium-based and iodinated contrast materials, and summarize the literature on the potential value of dedicated MR imaging contrast currently in development for the diagnosis of myocardial viability. The intensity of myocardial enhancement following infarction is related to two factors: expansion of the interstitial volume (15+/-2% in normal myocardium and 80+/-3% within necrosis) secondary to cell necrosis and perfusion abnormalities due to the absence of revascularization or lesions to the microcirculation. A kinetic model of contrast material properties within myocardium could be constructed from Kety's equation with regards to enhancement within the different myocardial tissues (viable myocardium, necrotic myocardium, fibrosis, no-reflow zones, stunned or hibernating myocardium). This model can be applied to both CT and MR since clinically available contrast agents are extracellular, inert and kinetically comparable. The development of dedicated contrast agents for viability and necrosis or molecular contrast agents open new horizons for preclinical research.

[How can we optimize medical orderings in intensive care unit (ICU)?]. / Optimisation des prescriptions en réanimation.

OBJECTIVES: To evaluate whether intensivists would accept to optimize their orderings of biological samplings, x-rays and target drugs and to assess the consequence on patient's outcome. STUDY DESIGN: Monocentric evaluation of medical economic procedure. METHODS: Meetings of consultants, registrars and residents started on Dec 21, 2006 with two to three sessions a year in order to evaluate the process of medical ordering. The physicians and pharmacists gave the results of orderings at each meeting. Orderings of systematic samplings, bedside x-rays and unjustified expansive drugs were discouraged, but target samplings and lung ultrasonography were encouraged. New residents were systematically taught about this programme. Meanwhile, monthly morbidity-mortality meetings were pursued in order to assess the consequences of this politics. RESULTS: While ICU total production increased by 3.4% and potentially evitable deaths decreased by 34%, annual expenses decreased by approximatively € 777,000 from 2006 to 2008. This was due to decreased orderings in biology by 30%, bedside x-rays by 10%, computed tomographic scans by 16% and target drugs by 35%. However, an increased ordering in four target drugs was observed in 2008 as compared with 2007. CONCLUSION: Multidisciplinary optimization of medical ordering can be efficient in ICU. However, a profit-sharing with ordering physicians would be necessary to prolong these effects.

[Current indications for cardiac MR imaging]. / Indications cliniques appropriées de l'IRM en pathologie cardio-vasculaire.

MRI has acquired over the years a role in the evaluation of cardiovascular pathology especially with regards to its ability to assess right and left ventricular function and delayed postcontrast "viability" sequences. Current class I clinical indications include: viability for patients with ischemic cardiomyopathy and acute coronary syndrome, etiology and prognostic evaluation of non-ischemic cardiomyopathies including myocarditis and arrhytmogenic right ventricular cardiomyopathy, chronic pericarditis and cardiac masses, non-urgent aortic aneurysm and dissection, congenital cardiopathies: vascular malformations and follow-up after curative or palliative surgery. MRI provides a complete non operator dependent evaluation, and is particularly useful for follow-up since it may be repeated due to its absence of ionizing radiation

Comparison of the angiographic myocardial blush grade with delayed-enhanced cardiac magnetic resonance for the assessment of microvascular obstruction in acute myocardial infarctions.

BACKGROUND: Both myocardial blush grade (MBG) and cardiac magnetic resonance (CMR) are imaging tools that can assess myocardial reperfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). OBJECTIVES: We studied the relation between MBG and gadolinium-enhanced CMR for the assessment of microvascular obstruction (MVO) in patients with acute ST-elevated myocardial infarction (STEMI) treated by primary PCI. MATERIAL AND METHODS: MBG was assessed in 39 patients with initial TIMI 0 STEMI successfully treated by PCI, resulting in TIMI 3 flow grade and complete ST-segment resolution. These MBG values were related to MVO determined by CMR, performed between 2 and 7 days after PCI. Left ventricular (LV) volumes were determined at baseline and at 6-month follow-up. RESULTS: No statistical relation was found between MBG and MVO extent at CMR (P = 0.63). Regarding MBG 0 and 1 as a sign of MVO, the sensitivity and specificity of these scores were 53.8 and 75%, respectively. In this study, CMR determined MVO was the only significant LV remodeling predicting factor (beta = 31.8; P = 0.002), whatever the MBG status was. CONCLUSION: MBG underestimates MVO after an optimal revascularization in AMI compared with CMR. This study suggests the superior accuracy of delayed-enhanced magnetic resonance over MBG for the assessment of myocardial reperfusion injury that is needed in clinical trials, where the principal endpoint is the reduction of infarct size and MVO.

Presence and extent of cardiac magnetic resonance microvascular obstruction in reperfused non-ST-elevated myocardial infarction and correlation with infarct size and myocardial enzyme release.

OBJECTIVE: Microvascular obstruction (MO) is a factor of adverse outcome in patients with ST-elevated myocardial infarction (STEMI). We assessed the presence and extent of MO and its relationship with infarct size and left ventricular (LV) functional parameters after acute non-ST-elevated myocardial infarction (NSTEMI). METHODS: Twenty-five patients with first acute NSTEMI underwent a cine and first-pass perfusion cardiac magnetic resonance (CMR) study, with late gadolinium enhancement imaging 72 h after myocardial infarction. RESULTS: MO was detected in 32% of patients, and its extent comprised 0.5-3.1% of the total LV mass (mean 1.9 +/- 1.2%). Patients with MO had a significantly larger infarct size than patients without (14.1 +/- 5.9 vs. 5.3 +/- 4.1% LV mass; p < 0.001). There was no significant difference between both groups for the LV functional parameters and LV ejection fraction (58.5 +/- 6.8 vs. 62.6 +/- 9.6%; p = 0.29). Patients with MO showed a higher troponin I release (570 +/- 364 vs. 148 +/- 103 IU; p = 0.003) and a higher creatine kinase release (29,887 +/- 18,263 vs. 10,287 +/- 5,283 IU; p = 0.007). CONCLUSIONS: In patients with acute NSTEMI, MO has a frequency similar to that observed in patients with STEMI and also correlates with the infarct extent. The prognostic significance on clinical outcome remains to be shown in this specific population.

Acute myocarditis mimicking lateral myocardial infarction.

We report a case of myocarditis mimicking acute lateral myocardial infarction and treated as such initially, which was complicated by ventricular fibrillation a few hours after admission to the intensive care unit. The correct diagnosis was rapidly made using a low-dose delayed-enhanced cardiac multidetector computed tomography scan performed immediately after a normal coronary angiogram, demonstrating typical myocardial late hyperenhancement and good correlation with delayed enhanced magnetic resonance imaging. This case suggests that myocarditis can be accurately diagnosed by delayed-enhanced cardiac multidetector computed tomography in an emergency setting. The other lesson from this case is that patients presenting with severe clinical symptoms, important ECG signs and high myocardial enzyme levels should be closely monitored for at least 72 hours, even when myocardial infarction has been excluded.

Endovascular repair of the descending thoracic aorta: mid-term results and evaluation of magnetic resonance angiography.

AIM: The endoluminal stent-grafting represents an alternative to surgery in the treatment of lesions of the descending thoracic aorta. The purpose of the present study was to evaluate the mid-term results of the Talent stent-graft in the different indications of aortic disease and the use of magnetic resonance angiography (MRA) in the diagnosis of complications. METHODS: Over a 3-year period, 23 patients with a high surgical risk and presenting a localized lesion of the descending thoracic aorta had an implantation of a Talent stent-graft. Indications were degenerative aneurysm (n=13), false aneurysm (n=7) and penetrating atherosclerotic ulcer (n=3). The feasibility of the endovascular treatment and sizing of the aorta and stent-grafts were determined pre-operatively by MRA and intraoperative angiography. Immediate and mid-term technical and clinical success were assessed by clinical and MRA follow-up. RESULTS: Endovascular treatment was completed successfully in all patients with no conversion to open repair. There was no intraoperative mortality. The mean operative time was 38+/-7 min. Primary success rate was 100%. We didn't have perioperative mortality. The mean follow-up period was 15+/-5 months. The survival rate was 97% (n=22). Regression of the aneurysmal size was observed in 70% (n=16). MRA diagnosed 3 over 4 postoperative endoleaks that were not diagnosed with the CT-scan, and did not interfere with the nitinol structure of the stent-graft. CONCLUSIONS: Endovascular treatment of the various localized diseases of the descending thoracic aorta is a promising, feasible, alternative technique to open surgery in well selected patients. MRA is well adapted to diagnose postoperative endoleaks.

[Cardiac CT: What role should it play in coronary artery disease?]. / Scanner cardiaque: quelle place dans la maladie coronaire?

The recent developments in the multi-slice CT scanner require evaluation of the clinical indications of this new tool for imaging coronary arteries. Improvements in spatial and temporal resolution with this new generation of CT (16 slices and more) allow the acquisition of coronary arteries with a sufficient quality in the majority of cases. After a short review of the technical principles of the cardiac CT, this article considers the clinical indications of this new method in the general evaluation of coronary artery disease.

Role of glycolysis in the energy production for the non-mechanical myocardial work in isolated pig hearts.

BACKGROUND: The dissociation of mechanical from non-mechanical energy utilisation can be studied using BDM (2,3-butanedione monoxime), which inhibits the actin-myosin interaction without inhibiting Ca2+ transport. The objective of the present study was to establish if increasing the non-mechanical energy demand of perfused isolated pig hearts by dobutamine stimulation requires glycolysis with increased exogenous glucose uptake. METHODS: Five isolated pig hearts (CTRL) were perfused for 90 min at constant flow (1 ml g(-1) min(-1)) with non-recirculating blood containing 30 mM BDM and 26 MBq/l of fluorine-18 2-fluoro-2-deoxyglucose (IFDG). This was compared with five hearts (DOBU) subjected to the same protocol for the first 30 min and then to dobutamine (1.5 microM) for the following 30 min and dobutamine (4 microM) for the last 30 min. Five other isolated hearts were perfused as for the DOBU group but without BDM (CTRLDOBU). Using a clinical PET scanner, glucose uptake was assessed by estimating 18FDG uptake using linear regression. The slope variations were compared using a global test of coincidence. RESULTS: Heart rate was at 100 +/- 2 b.p.m. in the CTRL group and at 180 +/- 7 b.p.m. in the DOBU group. 18FDG uptake was homogeneous within the whole myocardium and we observed a linear and regular increase in both the CTRL and DOBU groups (p, NS). In the CTRLDOBU group, 18FDG uptake was also homogeneous within the whole myocardium, but slopes of 18FDG uptake during dobutamine perfusion were higher than without dobutamine. CONCLUSION: In blood-perfused isolated pig hearts, exogenous glucose is not necessarily required when non-mechanical energy is increased by dobutamine stimulation. These findings suggest that ATP derived from glycolysis is not necessary to preserve myocardial Ca2+ transport during beta-adrenergic stimulation.

Slaughterhouse blood as a perfusate for studying myocardial function under ischemic conditions.

Metabolic studies using the in vitro non-recirculating blood-perfused isolated heart model require large volumes of blood. The present study was designed to determine whether heterologous pig blood collected from a slaughterhouse can be used as perfusate for isolated pig hearts perfused under aerobic and constant reduced flow conditions. Eight isolated working pig hearts perfused for 90 min at a constant flow of 1.5 ml g(-1) min(-1) with non-recirculated blood diluted with Krebs-Henseleit bicarbonate buffer at a hematocrit of 23% were compared to eight hearts subjected to the same protocol but perfused only with Krebs-Henseleit bicarbonate buffer solution. Hearts were paced at 100 bpm and subjected to aerobic perfusion at 38 degrees C. Hearts were weighed before perfusion and at the end of the experiment and the results are reported as percent weight gain (mean +/- SD). Comparisons between groups were performed by the Student t-test (P<0.05). After 90 min of perfusion with modified Krebs-Henseleit, perfused hearts presented a larger weight gain than blood-perfused hearts (39.34 +/- 9.27 vs 23.13 +/- 5.42%, P = 0.003). Left ventricular end-diastolic pressure was higher in the modified Krebs-Henseleit-perfused group than in the blood group (2.8 +/- 0.4 vs 2.3 +/- 0.3 mmHg, respectively, P = 0.01). We conclude that heterologous blood perfusion, by preserving a more physiological myocardial water content, is a better perfusion fluid than modified Krebs-Henseleit solution for quantitative studies of myocardial metabolism and heart function under ischemic conditions.

Slaughterhouse blood as a perfusate for studying myocardial function under ischemic conditions

Metabolic studies using the in vitro non-recirculating blood-perfused isolated heart model require large volumes of blood. The present study was designed to determine whether heterologous pig blood collected from a slaughterhouse can be used as perfusate for isolated pig hearts perfused under aerobic and constant reduced flow conditions. Eight isolated working pig hearts perfused for 90 min at a constant flow of 1.5 ml g-1 min-1 with non-recirculated blood diluted with Krebs-Henseleit bicarbonate buffer at a hematocrit of 23 percent were compared to eight hearts subjected to the same protocol but perfused only with Krebs-Henseleit bicarbonate buffer solution. Hearts were paced at 100 bpm and subjected to aerobic perfusion at 38ºC. Hearts were weighed before perfusion and at the end of the experiment and the results are reported as percent weight gain (mean ± SD). Comparisons between groups were performed by the Student t-test (P<0.05). After 90 min of perfusion with modified Krebs-Henseleit, perfused hearts presented a larger weight gain than blood-perfused hearts (39.34 ± 9.27 vs 23.13 ± 5.42 percent, P = 0.003). Left ventricular end-diastolic pressure was higher in the modified Krebs-Henseleit-perfused group than in the blood group (2.8 ± 0.4 vs 2.3 ± 0.3 mmHg, respectively, P = 0.01). We conclude that heterologous blood perfusion, by preserving a more physiological myocardial water content, is a better perfusion fluid than modified Krebs-Henseleit solution for quantitative studies of myocardial metabolism and heart function under ischemic conditions

Temporal covariance analysis of first-pass contrast-enhanced myocardial magnetic resonance images.

In this paper a temporal covariance method designed to analyze a Magnetic resonance (MR) image sequence of myocardial perfusion is presented. This method is used to map the first-pass transit of a contrast agent (Gd-chelates) through the heart. A map of bolus transit delay is constructed pixel by pixel corresponding to a myocardial reference using a temporal covariance measure. The resulting covariance map is a parametric image representing regions with different temporal dynamics. The proposed method is evaluated in 14 patients with coronary artery disease and eight healthy volunteers. Under rest and stress, covariance method is able to reveal a perfusion defect in stenosed coronary-artery-related myocardium. Furthermore, the method presents the advantage of its easy implementation and real-time parametric map construction.

Neuro-fuzzy systems for computer-aided myocardial viability assessment.

This paper describes a multimodality framework for computer-aided myocardial viability assessment based on neuro-fuzzy techniques. The proposed approach distinguishes two main levels: the modality-independent inference level and the modality-dependent application level. This two-level distinction releases the hard constraint of multimodality image registration. An abstract description template is used to describe the different myocardial functions (contractile function, perfusion, metabolism). Parameters extracted from different image modalities are combined to derive a diagnostic image. The neuro-fuzzy techniques make our system transparent, adaptive and easily extendable. Its effectiveness and robustness are demonstrated in a positron emission tomography/magnetic resonance imaging data fusion application.

[Hypoxemia secondary to inferior vena cava return into left atrium]. / Hypoxémie secondaire à un abouchement de la veine cave inférieure dans l'oreillette gauche.

The case of a right-to-left shunt-induced hypoxemia with an abnormal return of the inferior vena cava (AIVCR) into the left atrium (LA) is reported in a 30-year-old male with cyanosis and polycythemia. The chest X ray and the lung CT scan was normal. Spirometry was normal but the transfert-CO coefficient (KCO) was lowered. Hypoxemia was observed at rest and worsening during exercise. The alveolo-arterial oxygen tension difference under hyperoxia was increased (56 kPa). Contrast echocardiography (CEch) suggested the presence of an AIVCR with a right-to-left shunt only observed by the inferior route. The inferior vena cava (IVC) angiography and the magnetic resonance imaging demonstrated an AIVCR characterized by a direct drainage of IVC in the left atrium. The good tolerance can be explained by the association of AIVCR with an inter-auricular septal defect resulting in a left-to-right shunt which partially corrected the right-to-left shunt. After surgical treatment, arterial blood gases normalized, KCO remained low and CEch became negative.