Cardiac MRI in Pulmonary Hypertension: From Magnet to Bedside.

Pulmonary hypertension (PH) is a disease characterized by progressive rise of pulmonary artery (PA) pressure, which can lead to right ventricular (RV) failure. It is usually diagnosed late because of the nonspecificity of its symptoms. RV performance and adaptation to an increased afterload, reflecting the interaction of the PA and RV as a morphofunctional unit, constitute a critical determinant of morbidity and mortality in these patients. Therefore, early detection of dysfunction may prevent treatment failure. Cardiac MRI constitutes one of the most complete diagnostic modalities for diagnosing PH. It allows evaluation of the morphology and hemodynamics of the PA and RV. Several cine steady-state free-precession (SSFP)-derived parameters (indexed RV end-diastolic volume or RV systolic volume) and phase-contrast regional area change have been suggested as powerful biomarkers for prognosis and treatment. Recently, new cardiac MRI sequences have been added to clinical protocols for PH evaluation, providing brand-new information. Strain analysis with myocardial feature tracking can help detect early RV dysfunction, even with preserved ejection fraction. Four-dimensional flow cardiac MRI can enhance assessment of advanced RV and PA hemodynamics. Late gadolinium enhancement (LGE) imaging may allow detection of replacement fibrosis in PH patients, which is associated with poor outcome. T1 mapping may help detect interstitial fibrosis, even with normal LGE imaging results. The authors analyze the imaging workup of PH with a focus on the role of morphologic and functional cardiac MRI in diagnosis and management of PH, including some of the newer techniques. Online supplemental material is available for this article. ©RSNA, 2020.

Approach to Pulmonary Hypertension: From CT to Clinical Diagnosis.

Pulmonary hypertension (PH) is a condition characterized by increased pressure in the pulmonary circulation. It may be idiopathic or arise in the setting of other clinical conditions. Patients with PH tend to present with nonspecific cardiovascular or respiratory symptoms. The clinical classification of PH was recently revised at the World Health Organization symposium in Nice, France, in 2013. That consensus statement provided an updated classification based on the shared hemodynamic characteristics and management of the different categories of PH. Some features seen at computed tomography (CT) can suggest a subtype or probable cause of PH that may facilitate placing the patient in the correct category. These features include findings in the pulmonary arteries (peripheral calcification, peripheral dilatation, eccentric filling defects, intra-arterial soft tissue), lung parenchyma (centrilobular nodules, mosaic attenuation, interlobular septal thickening, bronchiectasis, subpleural peripheral opacities, ground-glass opacities, diffuse nodules), heart (congenital lesions, left heart disease, valvular disease), and mediastinum (hypertrophied bronchial arteries). An approach based on identification of these CT features in patients with PH will allow the radiologist to play an important role in diagnosis and help guide the clinician in management of PH. ©RSNA, 2018.

International cooperation in radiology training: A multipronged approach.

INTRODUCTION: Medical imaging has undergone significant technical advancements in recent years, posing a considerable challenge for radiologists to stay up-to-date with emerging modalities and their applications in daily practice. This challenge is even more daunting in developing countries with limited resources compared to the US and other developed nations with greater economic assets. The collaboration between the United States and other advanced nations with radiological institutions in Latin America has been a significant achievement in the pursuit of new opportunities for continuous medical education. The aim of this study was to evaluate the effectiveness of international collaborations among Spanish-speaking Latin American institutions and radiologists through a survey. MATERIALS AND METHODS: A group of radiologists and institutions from various countries, including the USA, Spain, and Argentina, who have been working together for several years to improve Radiology education across Latin America, were selected. An online survey was conducted. The survey included questions about interest in the activities, participation, and impact of radiologic education during these educational efforts. RESULTS: The survey received responses from 166 participants, all of whom reported knowledge of at least one type of educational activity. The most well-known activity was ALAT Webinars. The primary motivators for participation were the quality of the content and the opportunity to learn new information. Additionally, improving local education in radiology and receiving expert advice on radiology issues were identified as priorities for participation in international collaborations. The Cronbach alpha coefficient was calculated for individual and global Likert questions, resulting in a global score of 0.96. CONCLUSION: The study confirms the significance of a multifaceted approach to address gaps in radiology education. While traditional models have relied on hosting international visitors or sending US teachers abroad, the results suggest that using a variety of methods will have a greater impact than relying on a single technique for those who benefit most from collaborative efforts.

Primary pericardial tumors.

Primary pericardial tumors are rare and may be classified as benign or malignant. The most common benign lesions are pericardial cysts and lipomas. Mesothelioma is the most common primary malignant pericardial neoplasm. Other malignant tumors include a wide variety of sarcomas, lymphoma, and primitive neuroectodermal tumor. When present, signs and symptoms are generally nonspecific. Patients often present with dyspnea, chest pain, palpitations, fever, or weight loss. Although the imaging approach usually begins with plain radiography of the chest or transthoracic echocardiography, the value of these imaging modalities is limited. Cross-sectional imaging, on the other hand, plays a key role in the evaluation of these lesions. Computed tomography and magnetic resonance imaging allow further characterization and may, in some cases, provide diagnostic findings. Furthermore, the importance of cross-sectional imaging lies in assessing the exact location of the tumor in relation to neighboring structures. Both benign and malignant tumors may result in compression of vital mediastinal structures. Malignant lesions may also directly invade structures, such as the myocardium and great vessels, and result in metastatic disease. Imaging plays an important role in the detection, characterization, and staging of pericardial tumors; in their treatment planning; and in the posttreatment follow-up of affected patients. The prognosis of patients with benign tumors is good, even in the few cases in which surgical intervention is required. On the other hand, the length of survival for patients with malignant pericardial tumors is, in the majority of cases, dismal.

Imaging patients with cardiac trauma.

In the United States, trauma is the leading cause of death among those who are 1-44 years old, with cardiovascular injuries representing the second most common cause of traumatic death after central nervous system injuries. Evaluation of trauma patients with suspected cardiac injury may be complex and include electrocardiography, measurement of cardiac biomarkers, and imaging examinations. Contrast material-enhanced computed tomography (CT) has become one of the most valuable imaging tools available for evaluating hemodynamically stable patients with suspected cardiac injury. The presence of hemopericardium, with or without cardiac tamponade, is one of the most significant findings of cardiac injury. Other complications that result from blunt cardiac injury, such as pericardial rupture and cardiac herniation, may be readily depicted at multidetector CT. Assessment of patients with cardiac injuries, particularly those with penetrating injuries, is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. Patients who are hemodynamically stable, particularly those with penetrating cardiac injuries, also may benefit from a timely imaging examination. In addition to chest radiography, other available modalities such as transthoracic and transesophageal echocardiography, nuclear medicine, and magnetic resonance imaging may play a role in selected cases.

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification.

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

Coronary-cameral fistula with double-chambered right ventricle: appearance on cardiac magnetic resonance imaging and 3D printed anatomic modeling.

The present case illustrates cardiac magnetic resonance imaging (MRI) and three-dimensional (3D) printed anatomic model findings of a coronary-cameral fistula (CCF) and double-chambered right ventricle (DCRV). A pregnant woman presented with palpitations and near syncope. A non-contrast cardiac MRI showed CCF connecting to a DCRV. Post-delivery, the patient had a contrast-enhanced MRI and 3D printed anatomic model to better evaluate her aberrant anatomy.

Chest radiography in thoracic polytrauma.

OBJECTIVE: Chest radiography is the first-line imaging examination for assessment of thoracic polytrauma, serving to evaluate the extent of injury and facilitate early triage to observation, further imaging, or immediate surgical intervention. The objective of this article is to review the spectrum of injuries that occur in the chest and upper abdomen after blunt and penetrating trauma. Pathophysiology, imaging findings, and management recommendations will be discussed for injuries to the chest wall, diaphragm, pleura, lungs, mediastinum, heart, aorta, and great vessels. CONCLUSION: Chest radiography plays an important role in the initial evaluation of blunt and penetrating chest trauma, providing rapid imaging information to supplement the history and physical examination. In the emergency department, familiarity with the spectrum of injuries that can occur in the chest and upper abdomen is important for accurate interpretation of chest radiographs as well as establishment of appropriate recommendations for management and follow-up.

A pattern-based approach to assessment of delayed enhancement in nonischemic cardiomyopathy at MR imaging.

Although delayed contrast material-enhanced cardiac magnetic resonance (MR) imaging has traditionally been used to evaluate ischemic disease and myocardial viability, it is increasingly being used in the evaluation of nonischemic cardiomyopathies. Unlike myocardial infarction, which demonstrates subendocardial or transmural delayed contrast enhancement in a vascular distribution, nonischemic cardiomyopathies demonstrate enhancement that is not limited to a vascular territory. In combination with other cardiac MR imaging features, the location (subendocardial, transmural, subepicardial, or mesocardial) and pattern (patchy or diffuse) of abnormal delayed myocardial enhancement allow differentiation between ischemic (infarct-related) and nonischemic cardiomyopathies and, in cases of nonischemic cardiomyopathy, narrowing of the differential diagnosis. With use of a structured approach, delayed contrast-enhanced cardiac MR imaging can be helpful in the early detection and appropriate treatment of nonischemic cardiomyopathies.

Practical applications of magnetic resonance in congenital heart disease.

Cardiac magnetic resonance is a powerful, rapidly advancing technology that complements other imaging modalities in the noninvasive evaluation of congenital heart disease. Magnetic resonance plays an important role in diagnosis and follow-up by assessing anatomic features, functional effects, and postoperative complications. An understanding of the pathophysiology and imaging characteristics of various congenital heart lesions is essential for effective implementation and accurate interpretation of the cardiac magnetic resonance examination.

Non-coronary cardiac CT imaging.

Cardiac multidetector CT (MDCT) has moved from purely anatomic imaging, to assessment of cardiac function. Significant advances since the advent of multidetector CT now make it feasible to assess not only the coronary arteries, but also ejection fraction, ventricular volumes, myocardial mass and the presence of wall-motion abnormalities. Advances include improvements in EKG-gating, including improvements in temporal resolution, as well as the addition of delayed contrast-enhanced methods. Anatomic imaging has improved as well, with thinner collimation and better reconstruction methods. Three-dimensional software programs now permit excellent surface rendered displays and multiplanar reconstructions suitable as surgical and procedural "road maps."

A 43-year-old man with antisynthetase syndrome presenting with acute worsening of dyspnea.

A 43-year-old man with antisynthetase syndrome was seen in our pulmonary clinic for worsening dyspnea. He was recently diagnosed with antisynthetase syndrome because he had nonspecific interstitial pneumonitis on a surgical lung biopsy and polymyositis associated with anti-Jo-1 and anti-SSA-52 autoantibodies. Along with his worsening dyspnea, he also had a dry cough, lower extremity edema, and abdominal distension. He had gained 11 kg over 1 month. He had been taking prednisone 40 mg daily 2 months prior, which had been recently weaned to 20 mg daily. He had also been on mycophenolate mofetil but had recently discontinued it on his own.

Asbestos-related lung disease: a pictorial review.

Asbestos exposure can lead to a variety of adverse effects in the thorax. Although currently in the western world, levels of exposure are kept in check by strict regulations, history of previous asbestos exposure continues to have an effect on many, owing to the latent nature of the pathophysiological response of the body to the inhaled fibers. The adverse effects of asbestos generally fall under 3 categories: pleural disease, lung parenchymal disease, and neoplastic disease. Effects on the pleura include pleural effusions, plaques, and diffuse pleural thickening. In the parenchyma, rounded atelectasis, fibrotic bands, and asbestosis are observed. Differentiating asbestosis from other forms of interstitial lung diseases, such as idiopathic pulmonary fibrosis, usual interstitial pneumonia, smoking-related lung disease, and mixed interstitial lung diseases, is important because the prognosis, course of disease, and management of the patient should be tailored based on the specific etiology of the disease. In this review, imaging findings specific to asbestosis are discussed. Finally, exposure to asbestos can lead to neoplastic disease such as pleural mesothelioma, peritoneal mesothelioma, and bronchogenic carcinoma. The purpose of this article is to review the effects of asbestos exposure in the thorax, pathophysiology of these responses, and disease course. Particular emphasis is placed on the radiographic appearance of the disease, discussion of various imaging modalities and their utility, and the role of imaging in the management of patients with previous asbestos exposure and asbestos-related pulmonary disease.

How to plan and perform a cardiac MR imaging examination.

Because of the enormous economic and social impact of cardiovascular disease in the United States there is a need for improved noninvasive diagnosis. Cardiac MR imaging isa versatile, comprehensive technique for assessing cardiac morphology and function. With an understanding of cardiac anatomy and physiology and MR imaging physical principles,cardiac MR imaging can be performed and can play an important role in patient management. This article provides the reader with a basic understanding of cardiac MR imaging and the practical applications required to perform cardiac MR imaging.

Magnetic resonance imaging of cyanotic and noncyanotic congenital heart disease.

MRI has become an important imaging tool that complements echocardiography in the noninvasive evaluation of congenital heart defects. It can play a crucial role in diagnosis by assessing anatomic and functional features in CHD and identifying complications and postoperative sequelae. The performance and application of cardiac MRI require not only knowledge of the clinical question that needs to be addressed but knowledge of the anatomic characteristics of a variety of congenital heart lesions. A knowledge of the advantages and disadvantages of the different imaging sequences also is important so as to optimize and expedite the examination.

Performing cardiac MR imaging: an overview.

Because of the enormous economic and social impact of cardiovascular disease in the United States, there is a need for improved noninvasive diagnosis. Cardiac MR imaging is a versatile, comprehensive technique for assessing cardiac morphology and function. With an understanding of cardiac anatomy and physiology as well as MR physical principles, cardiac MR imaging can be performed and play an important role in patient management.

Radiologic findings of 2 commonly used cardiac septal occluders with clinical correlation.

Transcatheter closure of an atrial septal defect, patent foramen ovale, or post-myocardial infarction ventricular septal defect has become a safe and effective alternative to medical and surgical therapy. Although the use of transcatheter closure of septal defects is becoming increasingly more popular, there are few reports of the radiographic appearance of the closure devices. We report the chest radiographic findings in 36 patients after transcatheter closure of septal defects with Amplatzer or CardioSEAL occluders in an effort to aid radiologists in recognizing the appearances of these devices and enable them to confirm proper positioning.

Primary leiomyosarcoma of the pulmonary artery: a diagnostic dilemma.

Primary leiomyosarcoma of the pulmonary artery is a rare malignancy arising from the multipotential mesenchymal cell of the intima of the pulmonary artery. Due to its rarity and nonspecific clinical symptoms, the correct diagnosis and proper management are often delayed. Furthermore, it is frequently misdiagnosed as pulmonary embolism, mediastinal mass, pulmonary stenosis and lung cancer. Therefore, it is important to consider primary leiomyosarcoma of the pulmonary artery a possibility when a persistent filling defect is present in the pulmonary artery and there is no response to optimal anticoagulation treatment. Radiologic findings such as a unilateral mass continuously filling the pulmonary artery, inhomogenous enhancement, vascular distension, extravascular invasion into adjacent structure or uptake in the area of tumor on the FDG-PET can be helpful when differentiating pulmonary artery sarcoma (PAS) from chronic thromboembolism.