Progressive extreme biatrial enlargement following mitral valve replacement.

Patients with mitral valve disease and extreme enlargement of the left atrium usually exhibit significant decrease in chamber size following corrective mitral valve surgery. We describe a patient in whom extreme right and left atrial enlargement developed, and progressed following mitral valve replacement, with no evidence of prosthetic valve malfunction or tricuspid valve disease.

Echocardiographic source of early anterior systolic motion in late systolic mitral valve prolapse.

The echocardiographic features of patients with parachute mitral valve have revealed the combination of an early systolic movement of the mitral valve and late systolic prolapse. Cross-sectional echocardiographic and angiographic studies showed that the early systolic anterior motion was produced by the presence of a flail scallop of the anterior mitral leaflet in the left ventricular outflow tract.

Pulmonary function in single lung transplantation for chronic obstructive pulmonary disease.

The primary determinants of pulmonary function after heart-lung or double lung transplantation are the volume and compliance of the recipient's thoracic cage. This study evaluated the influence of recipient chest wall factors on static and dynamic lung volumes after single lung transplantation for chronic obstructive pulmonary disease. Fourteen patients with chronic obstructive pulmonary disease received 15 single lung transplants (one retransplant). Posttransplantation follow-up data at 3 and 6 months, in the absence of infection or rejection, were available in nine patients. Overall pulmonary function at 6 months improved from preoperative levels to 55% to 65% of predicted values (forced vital capacity 38% to 55%, forced expiratory volume at 1 second 18% to 55%, maximum voluntary ventilation 21% to 65%), and allograft-specific pulmonary function improved to nearly normal predicted single-lung values (forced vital capacity 89%, forced expiratory volume at 1 second 90%, maximum voluntary ventilation 105%). Postoperative pulmonary function in these patients correlated significantly with preoperative thoracic volume measured by planimetry of chest radiographs. No correlation between postoperative pulmonary function was demonstrated with either the estimated volume of donated lung tissue or relative donor-to-recipient size matching. These findings support the concept that recipient chest wall factors determine postoperative pulmonary function in patients undergoing single lung transplantation for chronic obstructive pulmonary disease. Furthermore, the allograft lung functions at a normal level for the recipient and does not appear to be constrained by hyperinflation of the contralateral lung.

Patient selection for cardiac surgery in left ventricular power failure.

Nineteen patients in acute left ventricular power failure following acute myocardial infarction were given support with intraaortic balloon pumping and underwent cardiac catheterization. Hemodynamic response to disastolic augmentation, results of left ventriculography, and observations of selective coronary arteriography were evaluated to determine which patients could survive without operation, which would require operation to survive, and which could be predicted not to survive operation. Of ten patients who underwent operation, three were long-term survivors. Two patients predicted to have a good prognosis without surgery did survive. Of three patients who had been determined to require operation but not undergo it, two died in the hospital and one a month later. The four patients whose conditions were considered inoperable died in the hospital. The results indicate that current methods of predicting the need for corrective surgery are relatively accurate and that the rate of survival in surgically treated patients may be increased.

A temporary catheter-tip aortic valve: hemodynamic effects on experimental acute aortic insufficiency.

A catheter-mounted polyurethane cusp was designed to act as a temporary prosthetic aortic valve in the ascending aorta. Acute aortic insufficiency was created in 15 dogs by transventricular tearing of the two aortic valve leaflets with a wire hook. Hemodynamic variables were measured during aortic insufficiency and with the prosthetic valve in place. Comparison of the values showed that the prosthesis functioned as a competent aortic valve. Aortic diastolic pressure increased by 62 +/- 42%, pulse pressure was lowered by 44 +/- 9%, and left ventricular end-diastolic pressure decreased by 45 +/- 18%. Neither cardiac output, coronary blood flow, nor peak systolic pressure was significantly altered. The observed hemodynamic improvement and the simplicity of the design and application suggest that the prosthetic aortic valve may be applicable in the temporary treatment of decompensated aortic insufficiency.

Helical computed tomography for the evaluation of tracheal stenosis.

BACKGROUND: Helical computed tomography with multiplanar reconstruction (CT/MPR) was used to study proximal airway stenosis. METHODS: Twenty-eight helical CT/MPR studies were obtained in 25 patients with known or suspected stenosis of the trachea or main bronchi. Computed tomographic results were compared with planar tomograms and bronchoscopic evaluation of the airway. RESULTS: CT/MPR accurately demonstrated the site and degree of tracheal and main bronchial stenoses with a sensitivity of 93%, a specificity of 100%, and an accuracy of 94%. There was one false negative study in a patient with tracheomalacia. In a second patient, a tracheal web was only apparent on nonstandard viewing windows. CONCLUSIONS: CT/MPR provides good anatomic detail and is an increasingly available technique. Potential drawbacks include the need for a longer breath-hold (15 to 45 seconds) and increased complexity of data compared with conventional tomograms. Helical CT/MPR is useful in the preoperative evaluation of these patients and, as experience accumulates, may replace the use of conventional tomograms.

Aspects of chest imaging in the intensive care unit.

Timely performance and accurate interpretation of portable chest radiographs in the ICU setting are fundamental components of quality care. Teamwork between intensive care clinicians and radiologists is necessary to assure that the appropriate studies, of high technical quality, are obtained. By working together to integrate available clinical information with systematic comprehensive analysis of images, accurate diagnoses can be made, optimal treatment instituted, and successful outcomes optimized.

Evaluation of competence in the interpretation of chest radiographs.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine relative rates of missed diagnoses for radiologists as a measure of competence in interpreting chest radiographs. MATERIALS AND METHODS: Cases involving differing interpretations of chest radiographs were collected from January 1994 through December 1999 by faculty (chest and nonchest radiology specialists) in an academic radiology department. A quarterly peer-review process designated cases months after the fact, and anonymously, as no miss or as class I (nondiagnosable), class II (very difficult diagnosis), class III (should be diagnosed most of time), or class IV (should almost always be diagnosed) missed diagnoses. The rates and classes of missed diagnoses were compared among chest faculty and for the nonchest radiology specialists as a group. RESULTS: Chest radiologists read 184,977 studies, and nonchest radiologists read 300,684 studies. Of these, 243 missed diagnoses were classified (classes I and II, 184 cases; class III, 50; and class IV, nine). No difference was detected in the rate of class III and IV misses among chest faculty, but nonchest faculty had significantly more class III (P = .022) and class IV misses (P = .016). CONCLUSION: Random sampling of differing interpretations can yield a relative rate of missed diagnoses for radiologists. No difference was detected in clinically important misses (ie, classes III and IV) among chest radiologists, but a statistically significantly higher rate of seemingly obvious misdiagnoses was found for nonchest specialty radiologists. Potential biases may have influenced this analysis, including disease prevalence, sampling, clinical factors, observer variability, and truth-in-diagnosis.

High-resolution CT detection of lacerations in the transplanted lung after transbronchial biopsy.

Relatively large tissue samples may be obtained from the lung with the "Alligator" biopsy forceps. We report the radiographic and high-resolution computed tomography (HRCT) appearances of six pulmonary lacerations in the transplanted lungs of three asymptomatic patients after transbronchial biopsy with this large caliber biopsy forceps. All patients had undergone transbronchial biopsy from 4 to 10 days before HRCT that was performed as part of routine surveillance after transplantation. The site and histopathologic findings of lung biopsies and negative microbiologic studies on bronchoalveolar washings correlated accurately with each pulmonary lesion seen. Laceration size varied from 9 to 20 mm (mean 14 mm) on HRCT. A thickened wall or surrounding alveolar reaction related to bronchoalveolar lavage or biopsy-induced hemorrhage was seen in five lesions. These simulated the appearance of lung abscess or invasive fungal disease. Only nonspecific alveolar opacities were noted on chest radiographs. The Alligator biopsy forceps may cause pulmonary lacerations in transplanted lungs that are detectable on HRCT but not on chest radiographs. Differentiation from opportunistic infection by CT criteria alone is difficult in these immunocompromised patients. CT studies in this population should be performed prior to transbronchial biopsy whenever possible.

Squamous cell carcinoma of the thymus with paraneoplastic hypercalcemia.

Primary thymic carcinoma is a rare neoplasm that in contradistinction to thymoma, is not supposed to be associated with a paraneoplastic syndrome. A 73-year-old man, with new onset of disorientation, was found to have an elevated serum calcium level as the cause. Computed tomography demonstrated a mediastinal mass, pericardial invasion, and metastases to the lung. Examination of a biopsy specimen revealed thymic squamous cell carcinoma. Thus, a paraneoplastic syndrome, in this case hypercalcemia, does not exclude primary carcinoma of the thymus.

Rib compression of the coronary arteries.

This report describes the finding of coronary artery narrowing caused by compression by an overlying rib in two patients with cardiomegaly. There is probably no clinical significance to this finding. The primary differential diagnostic entity is myocardial bridging.

Monitoring and evaluating the quality and appropriateness of angiographic/interventional radiologic procedures.

The safety and efficacy of invasive radiologic procedures should be monitored in all departments that include such activities. Assessing the data arising from such monitoring and taking the actions needed to improve quality and appropriateness of care are additional steps that must be taken to meet the expectations of the JCAHO. The SCVIR has distributed to its membership for comment a proposal for a model program for monitoring and evaluating angiographic/interventional procedures that, if adopted by a department, would help meet external accrediting reviews. The SCVIR also has under study a proposal to develop a national data base that would act as a repository of information on invasive radiologic procedures. By voluntarily participating in the program, departments would receive feedback that periodically documents performance and compares it with national norms established by all participants in the program. If the data base is sufficiently detailed, distinct advantages of collaborative research could result. Data related to comparative technology assessment, cost-benefit analyses, and other derived information could then be made available to other physicians, the public, payers, and government agencies. The discipline of radiology would have a vehicle to influence and create national recommendations for health care policy decisions.

Abdominal wall cellulitis and sepsis secondary to percutaneous cecostomy.

We report 1 case of abdominal wall cellulitis and sepsis which developed following percutaneous placement of a Cope catheter for cecal decompression in a patient with Ogilvie's syndrome. This case highlights that further laboratory investigation and clinical evaluation are needed to determine the safest and most efficacious technique of percutaneous drainage.

Decision-making in radiotherapy for the cancer patient: the American College of Radiology Appropriateness Criteria Project.

The American College of Radiology Task Force on Appropriateness Criteria was developed in 1993 with the major objective of creating the most credible patient care guidelines possible. Oncology-related clinical conditions addressed by the Task Force pertain to the diagnosis of suspected disease and, after disease is diagnosed, its staging, treatment, and follow-up to determine the effectiveness of therapy.

Transplanted lungs: nodules following transbronchial biopsy.

PURPOSE: To determine how often nodules occur in lung allografts due to transbronchial biopsy and the temporal relationship between the development of these lesions and biopsy. MATERIALS AND METHODS: During 2 years, 141 computed tomographic (CT) studies and 324 transbronchial biopsies were performed in 40 patients who had undergone lung transplantation. CT images and chest radiographs were retrospectively evaluated for evidence of lung injury. RESULTS: Thirteen CT studies of 12 patients revealed transbronchial biopsy injury. Seven cavitary and nine solid nodules were seen a mean of 8.8 and 18.6 days after biopsy, respectively. Two nodules were detected prospectively on radiographs; seven, retrospectively. In two patients, nodules not seen on chest radiographs obtained immediately after biopsy were seen on radiographs obtained 8 and 12 days later. Fifteen lesions resolved. One lesion left a linear scar. CONCLUSION: Nodules that represent transbronchial biopsy lung injury are seen on CT images up to 1 month after biopsy and may not be evident on chest radiographs obtained immediately after biopsy.

Sarcoidosis: recurrence of primary disease in transplanted lungs.

PURPOSE: To assess findings of recurrent disease on thin-section computed tomographic (CT) studies and results of bronchoalveolar lavage and transbronchial biopsy (BAL-TBB) procedures performed in adult lung transplant recipients. MATERIALS AND METHODS: Between 1990 and 1993, 32 single-lung, 14 double-lung, and three heart-lung transplantation procedures were performed in 47 patients; 176 thin-section CT scans were reviewed, with a mean follow-up of 18.9 months after transplantation. RESULTS: Sarcoidosis was diagnosed after BAL-TBB of the lung allografts 3 and 15 months after transplantation in both patients without symptoms who received transplants for treatment of sarcoidosis. In one patient, diffuse miliary nodules seen on chest radiographs and thin-section CT scans disappeared after administration of an increased dose of corticosteroids; in the other patient, no radiologic finding of sarcoidosis was present. No recurrence was seen in patients who received transplants for treatment of other diseases. CONCLUSION: Recurrence of primary disease should be considered whenever abnormalities are seen on chest radiographs or thin-section CT scans. Sarcoidosis may recur with or without radiologic findings after transplantation.

Methods of cardiopulmonary support: a review for radiologists.

Physicians are generally aware of the use of bypass pumps during open heart surgery and of the intraaortic balloon pump in treatment of cardiogenic shock. In selected research centers, other advanced methods of cardiopulmonary support are being introduced. Some devices such as the total artificial heart fail clinical trials and disappear from use. Others, like some of the partial artificial hearts, improve outcomes and gain wider clinical use. Some devices temporarily support the circulation in patients recovering from acute circulatory collapse, whereas others provide longer-term circulatory support for patients awaiting transplantation. Permanently implanted devices provide circulatory assistance in cases of chronic, debilitating heart failure. Technology to support lung function in the setting of acute respiratory failure, allowing healing to take place, is also under study. Radiologists should be familiar with the operating principles and radiographic appearances of these emerging techniques to maintain their role as consultants to cardiopulmonary specialists.