Treatment-Related Changes in Left Atrial Structure in Atrial Fibrillation: Findings From the CABANA Imaging Substudy.

[Figure: see text].

Lipoma causing upper extremity deep vein thrombosis: a case report.

We report a case of lipoma in the right infraclavicular and axillary area compressing subclavian vein there by presenting with upper extremity deep venous thrombosis (UEDVT) and persistent symptoms of venous congestion. Patient was also found to be a heterozygous carrier of prothrombin 20210 gene mutation. Surgical excision of lipomatous tissue performed after 6 months of anticoagulation resulted in a complete resolution of symptoms.

Abnormal electron beam computed tomography results: the value of repeating myocardial perfusion single-photon emission computed tomography in the ongoing assessment of coronary artery disease.

OBJECTIVE: To determine whether asymptomatic patients with atherosclerosis, indicated by the presence of coronary artery calcium on electron beam computed tomography, are at enough risk for progression of disease to justify a repeated stress single-photon emission computed tomography (SPECT) examination after an initial normal to low-risk perfusion study. PATIENTS AND METHODS: We retrospectively identified patients who had abnormal results on electron beam computed tomography (coronary artery calcium score > 0) and normal to low-risk results on SPECT (defined as a summed stress score of 0-3) within a 3-month period from January 1, 1995, to October 31, 2002. Of the 504 identified patients, 285 remained after exclusion criteria were applied. Of the 285 patients, 69 (mean +/- SD age, 58.2 +/- 7.6 years; 91% male) underwent at least 1 repeated myocardial perfusion SPECT imaging study within 4 years of their initial assessment as normal or at low risk without recurrence of symptoms. The value of repeated SPECT imaging was assessed by detection of a substantial change in the repeated SPECT study and by documentation of a clinical event (death, nonfatal myocardial infarction, or revascularization). Follow-up was 100% complete at a mean of 4.3 +/- 1.6 years. RESULTS: Only 4 patients (6%) had a substantial progression in their SPECT risk category; substantial changes on the SPECT scans occurred only in patients with a coronary artery calcium score greater than 100. Three patients underwent revascularization, yielding a 5-year rate for survival free of revascularization of 94% (95% confidence interval, 88%-100%). No deaths or nonfatal myocardial infarctions were reported. CONCLUSION: The principal findings of this study indicate that asymptomatic patients with initial normal or low-risk results from stress SPECT performed because of abnormal coronary artery calcium scores who remain asymptomatic are at low risk of death, myocardial infarction, or coronary revascularization. Three patients underwent revascularization by percutaneous coronary intervention despite the absence of symptoms. A substantial change in SPECT results (defined as progression from normal or low-risk summed stress score to intermediate- or high-risk summed stress score) affected 6% of patients and was not associated with any adverse hard events (nonfatal myocardial infarction or death).

Aortic valve calcification: determinants and progression in the population.

BACKGROUND: Aortic valve calcification (AVC) is considered degenerative. Recent data suggested links to atherosclerosis or coronary disease (CAD). METHODS AND RESULTS: AVC and coronary artery calcifications (CAC) were prospectively assessed by Electron-Beam-Computed-Tomography in 262 population-based research participants > or = 60 years. AVC was frequent (27%) with aging (P<0.01) and in men (P<0.05). AVC was associated with diabetes, hypertension, higher body-mass-index, and serum glucose (all P<0.05). AVC was a marker of higher prevalence (P<0.01) and severity of CAD (CAC score: 441+/-802 versus 265+/-566, P<0.05) independently of age. After follow-up of 3.8+/-0.9 years, AVC score increased (94+/-271 versus 54+/-173, P<0.01, +11+/-32 U/year), faster with higher baseline AVC score (P<0.01). Compared with participants remaining free of AVC, de novo acquisition of AVC was associated with higher LDL-cholesterol (141+/-31 versus 121+/-27 mg/dL, P<0.05) and faster CAC progression (+78+/-87 versus +28+/-47 U/year, P<0.05). In multivariate analysis, LDL-cholesterol independently determined AVC acquisition while higher baseline AVC scores determined faster progression of existing AVC. CONCLUSION: In the population, AVC is frequent with aging and atherosclerotic risk factors. AVC is a marker of subclinical CAD. AVC is progressive, appearing de novo with progressive atherosclerosis whereas established AVC progresses independently of atherosclerotic risk factors and faster with increasing initial AVC loads.

ECG-gated cardiac CT angiography using 64-MDCT for detection of patent foramen ovale.

OBJECTIVE: The purpose of our study was to show the feasibility of ECG-gated, 64-MDCT cardiac angiography for the detection of patent foramen ovale (PFO). MATERIALS AND METHODS: Chart review was performed on 214 consecutive patients referred for clinically indicated 64-MDCT angiography. The study cohort consisted of 20 patients who had previously undergone transesophageal echocardiography (TEE). Blinded consensus review of each CT angiography was performed by two experienced cardiac radiologists and results were compared with TEE, which served as a reference standard. CT criteria for the diagnosis of PFO were distinct left atrial "flap" in the expected location of the septum primum, continuous column of contrast material connecting this flap to the right atrium, and a "jet" of contrast material from the column into the right atrium. RESULTS: Of the 20 patients who underwent both TEE and cardiac CT angiography, six (30%) were found to have a PFO by TEE. Using the presence of a left atrial flap as the only diagnostic criterion, all six cases of PFO were detected using CT (sensitivity = 100%). Of the 14 patients with no PFO seen on TEE, 12 of these were correctly identified using CT (specificity = 86%). Using all three criteria together, the sensitivity decreased to 66% and the specificity increased to 100%. CONCLUSION: ECG-gated cardiac CT angiography performed with a 64-MDCT scanner can be used to reliably detect PFO.

MR imaging of cardiac masses.

Cardiac MR imaging is the preferred method for assessment of cardiac masses. A comprehensive cardiac MR imaging examination for a cardiac mass consists of static morphologic images using fast spin-echo sequences, including single-shot techniques, with T1 and T2 weighting and fat suppression pulses as well as dynamic imaging with cine steady-state free precession techniques. Further tissue characterization is provided with perfusion and delayed enhancement imaging. Specific cardiac tumoral characterization is possible in many cases. When specific tumor characterization is not possible, MR imaging often can demonstrate aggressive versus nonaggressive features that help in differentiating malignant from benign tumors.

Relationship and prognostic value of coronary artery calcification by electron beam computed tomography to stress-induced ischemia by single photon emission computed tomography.

BACKGROUND: Stress single photon emission computed tomography (SPECT) is commonly performed in patients with abnormal electron beam computed tomography (EBCT) to define risk stratification, but the published prognostic data for patients undergoing both SPECT and EBCT are limited. The objective of the study was to examine the association and prognostic value between EBCT, coronary artery calcium score (CACS), and stress SPECT imaging. METHODS: We identified 835 patients (age 54.8 +/- 10.0 years, 77% male) who underwent EBCT and stress SPECT within a 3-month period. Coronary artery calcium score was categorized as normal (0), minimal (1-10), mild (11-100), moderate (101-400), and severe (>400). Single photon emission computed tomography summed stress score (SSS) was categorized as normal, low risk, intermediate risk, and high risk per Cedar Sinai criteria. Average follow-up was 4.8 +/- 3.2 years. End points were all-cause death, death/myocardial infarction (MI), and death/MI/late revascularization. RESULTS: The correlation of CACS to SSS was weak but statistically significant (r = +0.19, P < .001). The percentage of high-risk SSS increased with higher CACS scores; 4% of patients with normal EBCT and 18% with severe CACS had high-risk SSS. Coronary artery calcium score (chi2 = 11.4, P < .001), diabetes mellitus (chi2 = 4.6, P = .031), and chest pain class (chi2 = 8.7, P = .003) were independently associated with high-risk SPECT. The SSS (chi2 = 6.9, P = .009) and CACS (chi2 = 7.8, P = .005) were independently associated with mortality, as well as with both secondary end points of death/MI and death/MI/late revascularization. Only CACS predicted mortality in the 408 asymptomatic patients (chi2 = 5.2, P = .02), but these patients had an annual mortality of only 0.4% over the next 5 years. CONCLUSIONS: In selected patients undergoing both EBCT and SPECT, CACS is weakly correlated with SPECT SSS, likely reflecting the different information provided by EBCT and SPECT. Coronary artery calcium score is independently associated with high-risk SPECT after adjustment for clinical variables. Coronary artery calcium score and SSS are complementary for the prediction of mortality in symptomatic patients. Only CACS predicted mortality in the asymptomatic patients, but they had a low annual mortality.

Assessment of pulmonary thromboendarterectomy by tomographic electrocardiogram-gated equilibrium radionuclide angiocardiography compared with electron beam computed tomography.

BACKGROUND: Successful thromboendarterectomy for chronic thromboembolic pulmonary hypertension promptly improves right ventricular (RV) function by decreasing RV volume and increasing ejection fraction (EF). Single photon emission computed tomography (SPECT) equilibrium radionuclide angiocardiography (ERNA) has been validated as a measure of RV and left ventricular (LV) volume and EF. METHODS AND RESULTS: Nine patients with chronic thromboembolic pulmonary hypertension underwent electron beam computed tomography (EBCT) and SPECT ERNA cardiac studies before and after thromboendarterectomy. EBCT and SPECT ERNA measures of RV and LV volume and EF were compared. Before thromboendarterectomy, EBCT and SPECT ERNA RV and LV volumes and RV EF were similar. LV EF was within the normal range with both methods but was slightly greater (P = .004) when measured by EBCT (mean +/- SD, 0.61 +/- 0.08) compared with SPECT ERNA (0.54 +/- 0.10). Thromboendarterectomy measured by EBCT and SPECT ERNA produced marked similar and significant decreases in RV end-systolic (-72 +/- 59 mL vs -58 +/- 25 mL) and end-diastolic (-75 +/- 85 mL vs -76 +/- 32 mL) volumes and similar slight increases in RV EF (0.12 +/- 0.07 vs 0.05 +/- 0.06). Slight decreases in mean LV end-systolic (-19 +/- 23 mL vs -5 +/- 13 mL, P = .05) and end-diastolic (-32 +/- 53 mL vs -9 +/- 31 mL, P = .21) volumes occurred, with little change in mean LV EF (0.05 +/- 0.07 vs 0.00 +/- 0.10). CONCLUSIONS: SPECT ERNA is an accurate method for measuring RV and LV volume and EF before and after thromboendarterectomy.

Progression of subclinical coronary atherosclerosis: does obesity make a difference?

BACKGROUND: Obesity is associated with coronary artery calcification (CAC), a marker of the presence and extent of subclinical coronary atherosclerosis. Obesity adds incremental information in identifying those at higher risk of coronary heart disease to traditional risk factor assessment. The present study examined associations between obesity measures and progression of CAC in those at higher (> or =10%) and lower (<10%) 10-year coronary heart disease risk according to the Framingham risk equation. METHODS AND RESULTS: In this study, 443 asymptomatic white individuals >30 years of age (243 men) had baseline and follow-up CAC measurements an average of 8.9 years apart. Multivariable linear regression models were fit to determine associations of obesity measures at baseline with progression of CAC defined as log(e) of the difference between follow-up and baseline CAC area plus 1 divided by time (in years) between examinations, adjusting for baseline CAC quantity, age, sex, baseline hypertension status, and baseline cholesterol level. Among 329 participants (74.3%) in the lower-risk group, waist circumference (P=0.024), waist-to-hip ratio (P<0.001), body mass index (P=0.036), and being overweight compared with being underweight or of normal weight (P=0.008) were each significantly positively associated with progression of CAC. Among those at higher coronary heart disease risk, no baseline obesity measures were associated with CAC progression. CONCLUSIONS: Various measures of obesity were associated with increased progression of CAC in those at lower risk of coronary heart disease. Future studies examining the effectiveness of weight reduction strategies in reducing CAC progression among those with an otherwise favorable risk factor profile may be warranted.

Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation.

BACKGROUND: Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)-mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis. METHODS AND RESULTS: To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103+/-100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3+/-2 mm compared with 13+/-3 mm at baseline (P< or =0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4+/-3% of total perfusion compared with 22+/-10% in unaffected segments. At percutaneous intervention, these veins showed 80+/-13% stenosis, with a mean gradient of 12+/-5 mm Hg. This was significantly reduced to a residual stenosis of 9+/-8% (P< or =0.001) and a residual gradient of 3+/-4 mm Hg (P< or =0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13. CONCLUSIONS: Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.

Short-term hypoxic exposure at rest and during exercise reduces lung water in healthy humans.

Hypoxia and hypoxic exercise increase pulmonary arterial pressure, cause pulmonary capillary recruitment, and may influence the ability of the lungs to regulate fluid. To examine the influence of hypoxia, alone and combined with exercise, on lung fluid balance, we studied 25 healthy subjects after 17-h exposure to 12.5% inspired oxygen (barometric pressure = 732 mmHg) and sequentially after exercise to exhaustion on a cycle ergometer with 12.5% inspired oxygen. We also studied subjects after a rapid saline infusion (30 ml/kg over 15 min) to demonstrate the sensitivity of our techniques to detect changes in lung water. Pulmonary capillary blood volume (Vc) and alveolar-capillary conductance (D(M)) were determined by measuring the diffusing capacity of the lungs for carbon monoxide and nitric oxide. Lung tissue volume and density were assessed using computed tomography. Lung water was estimated by subtracting measures of Vc from computed tomography lung tissue volume. Pulmonary function [forced vital capacity (FVC), forced expiratory volume after 1 s (FEV(1)), and forced expiratory flow at 50% of vital capacity (FEF(50))] was also assessed. Saline infusion caused an increase in Vc (42%), tissue volume (9%), and lung water (11%), and a decrease in D(M) (11%) and pulmonary function (FVC = -12 +/- 9%, FEV(1) = -17 +/- 10%, FEF(50) = -20 +/- 13%). Hypoxia and hypoxic exercise resulted in increases in Vc (43 +/- 19 and 51 +/- 16%), D(M) (7 +/- 4 and 19 +/- 6%), and pulmonary function (FVC = 9 +/- 6 and 4 +/- 3%, FEV(1) = 5 +/- 2 and 4 +/- 3%, FEF(50) = 4 +/- 2 and 12 +/- 5%) and decreases in lung density and lung water (-84 +/- 24 and -103 +/- 20 ml vs. baseline). These data suggest that 17 h of hypoxic exposure at rest or with exercise resulted in a decrease in lung water in healthy humans.

Computed tomographic angiography of the coronary arteries: techniques and applications.

Computed tomographic coronary angiography (CT-CA) is a direct but minimally invasive method of visualizing coronary arteries. Multidetector-row computed tomography (MDCT) is currently the CT modality most commonly used for coronary artery imaging. MDCT has been successfully used to detect stenoses in coronary arteries and coronary artery bypass grafts and to assess congenital coronary anomalies. Patients should not undergo CT-CA with MDCT if they have an irregular heart rhythm, a heart rate greater than 70 beats/min, and contraindications to pharmacologic agents for heart rate control, or if they have severe coronary artery disease or are likely to require revascularization.

Constrictive pericarditis in 26 patients with histologically normal pericardial thickness.

BACKGROUND: Traditionally, increased pericardial thickness has been considered an essential diagnostic feature of constrictive pericarditis. Although constriction with a normal-thickness pericardium has been demonstrated clinically by noninvasive imaging, the details of clinicopathological correlates have not been described. METHODS AND RESULTS: A total of 143 patients with proven constriction underwent pericardiectomy at Mayo Clinic between 1993 and 1999. Their baseline characteristics, operative data, and pathological specimens were reviewed retrospectively. The pericardium was of normal thickness (< or =2 mm) in 26 patients (18%; group 1) and was thickened (>2 mm) in 117 (82%; group 2). The most common causes of constriction in group 1 included previous cardiac surgery, chest irradiation, previous infarction, and idiopathic disease. There was little difference in symptoms and findings on physical examination between the 2 groups. Microscopically, no patient had an entirely normal pericardium. Histopathological abnormalities in group 1 were mild and focal, including fibrosis, inflammation, calcification, fibrin deposition, and focal noncaseating granulomas. Pericardiectomy was equally effective in relieving symptoms regardless of the presence or absence of increased thickness. CONCLUSIONS: Pericardial thickness was not increased in 18% of patients with surgically proven constrictive pericarditis, although the histopathological appearance was focally abnormal in all cases. When clinical, echocardiographic, or invasive hemodynamic features indicate constriction in patients with heart failure, pericardiectomy should not be denied on the basis of normal thickness as demonstrated by noninvasive imaging.

Evaluation and clinical implications of aortic valve calcification measured by electron-beam computed tomography.

BACKGROUND: Electron-beam computed tomography (EBCT) is used to measure coronary calcification but not for aortic valve calcification (AVC). Its accuracy, association with aortic stenosis (AS) severity, and diagnostic and prognostic value with respect to AVC are unknown. METHODS AND RESULTS: In 30 explanted aortic valves, the AVC score by EBCT (1125+/-1294 Agatston units [AU]) showed a strong linear correlation (r=0.96, P<0.0001) with valvular calcium weight (653+/-748 mg) by pathology that allowed estimation of calcium weight as AVC score/1.7, with a small standard error of the estimate (53 mg). In 100 consecutive clinical patients, we measured AVC by EBCT and AS severity by echocardiographic aortic valve area (AVA). The AVC score was 1316+/-1749 AU (range 0 to 7226 AU). Intraobserver and interobserver variabilities were excellent (4+/-4% and 4+/-10%, respectively). AVC and AVA were strongly associated (r=0.79, P<0.0001) but had a curvilinear relationship that suggested that AVC and AVA provide complementary information. AVC score > or =1100 AU provided 93% sensitivity and 82% specificity for diagnosis of severe AS (AVA <1 cm2), with a receiver operator characteristic curve area of 0.89. AVC assessment by echocardiography was often more severe than by EBCT (P<0.0001). During follow-up, 22 patients either died, developed heart failure, or required surgery. With adjustment for age, sex, symptoms, ejection fraction, and AVA, the AVC score was independently predictive of event-free survival (risk ratio 1.06 per 100-AU increment [1.02 to 1.10], P<0.001), even after adjustment for echocardiographic calcifications. CONCLUSIONS: AVC is accurately and reproducibly measured by EBCT and shows a strong association and diagnostic value for severe AS. The curvilinear relationship between AVC and AVA suggests these measures are complementary, and indeed, AVC provides independent outcome information. Thus, AVC is an important measurement in the evaluation of patients with AS.

Clinical safety of magnetic resonance imaging early after coronary artery stent placement.

OBJECTIVES: Our aim was to examine the rate of adverse cardiac events in patients undergoing magnetic resonance imaging (MRI) <8 weeks after coronary stent placement. BACKGROUND: The risk of coronary stent thrombosis from dislodgement due to MRI early after stent placement is not well defined. Manufacturers recommend postponing MRI studies until eight weeks after coronary stent placement. METHODS: We analyzed the Mayo Clinic Rochester Percutaneous Coronary Intervention Database and examined records of 111 patients who underwent MRI <8 weeks after coronary stent placement treated with aspirin and a thienopyridine. Occurrence of death, myocardial infarction (MI), and repeat revascularization within 30 days of MRI were recorded. RESULTS: Magnetic resonance imaging (1.5 tesla) was performed within a median of 18 days (range, 0 to 54 days) after coronary stent placement. Four noncardiac deaths occurred, and three patients had repeat revascularization procedures. Stent thrombosis did not occur (95% confidence interval, 0% to 3.3%). CONCLUSIONS: Magnetic resonance imaging <8 weeks after coronary stent placement appears to be safe, and the risk of cardiac death or MI due to stent thrombosis is low. Postponing MRI does not appear to be necessary.

Atypical presentation of eosinophilic endomyocardial disease.

Idiopathic hypereosinophllic syndrome is classically defined as prolonged, unexplained peripheral eosinophilia in a patient presenting with evidence of end-organ damage. The heart is frequently Involved, resulting In eosinophilic endomyocardial disease and eventually restrictive cardlomyopathy. The mortality rate is high because of progressive heart failure or ventricular arrhythmias. We describe a patient who presented with a left ventricular apical thrombus without notable peripheral eosinophilia. Findings from clinical evaluation and extensive diagnostic testing, including right ventricular biopsy, were Inconclusive. Resection of the thrombus and subjacent endomyocardium revealed eosinophilic Infiltration of the endomyocardium, which led to the diagnosis of eosinophilic endomyocardial disease. Clinicians should be aware of the variable presentation of patients with eosinophil-associated endomyocardial disease so that affected patients may benefit from early diagnosis and treatment.