Andrea Romagnoli

Cardiac calcifications : Fetuin-A and other risk factors in hemodialysis patients

Cardiac calcifications are a frequent finding in hemodialysis for chronic renal failure. Several factors may play a role in the intimal and medial calcification of coronary arteries such as age and some known atherogenetic factors. In addition, Fetuin-A has been proposed as a protective agent through solubilization of calcium phosphate salt. Fetuin-A is also a marker of inflammatory-nutritional state, and its changes could be an expression of this condition. The aim of this cross-sectional study is to evaluate the relative importance of risk factors of calcifications with special regard to Fetuin-A. The study was conducted with 132 hemodialysis patients. They were subjected to multislice computed tomography for evaluation of calcium deposits in the heart. In addition, the patients were sampled for evaluation of calcium-phosphate parameters, lipid profile, nutritional and inflammatory markers, and also Fetuin-A. There was a wide variability of the extent of calcium deposits expressed as Agatston score, with only 9.3% of patients without calcifications. Age, hemodialysis age, sex, calcium-phosphate parameters, and lipid profile were important risk factors, together with nutritional and inflammatory status of the patients. An inverse correlation between coronary calcium score and Fetuin-A emerged from a multiple regression analysis. However, there was no significant difference in serum Fetuin-A among different grades of calcium score. By dividing the patients in tertiles of serum Fetuin-A, an association between low levels of Fetuin-A and high calcification score was found. Fetuin-A as dependent variable was strictly linked to prealbumin serum levels. In addition, there was a clear link between cardiac calcification scores and inflammatory-nutritional markers. Serum calcium and treatment with calcitriol emerged as predictive variables of coronary score. Fetuin-A could be involved in the process of calcification both in the case of markedly low serum levels, due to decreased prevention of calcium phosphate precipitation, and also as a marker of inflammation, a well-known risk factor of atherogenesis. Treatment with intravenous calcitriol could marginally enhance cardiac calcifications, probably through its hypercalcemic effect.

Risk factors of one year increment of coronary calcifications and survival in hemodialysis patients

BackgroundHeart and coronary calcifications in hemodialysis patients are of very common occurrence and linked to cardiovascular events and mortality. Several studies have been published with similar results. Most of them were mainly cross-sectional and some of the prospective protocols were aimed to evaluate the results of the control of altered biochemical parameters of mineral disturbances with special regard to serum calcium, phosphate and CaxP with the use of calcium containing and calcium free phosphate chelating agents. The aim of the present study was to evaluate in hemodialysis patients classic and some non classic risk factors as predictors of calcification changes after one year and to evaluate the impact of progression on survival.Methods81 patients on hemodialysis were studied, with a wide age range and HD vintage. Several classic parameters and some less classic risk factors were studied like fetuin-A, CRP, 25-OHD and leptin. Calcifications, as Agatston scores, were evaluated with Multislice CT basally and after 12-18 months.ResultsCoronary artery calcifications were observed in 71 of 81 patients. Non parametric correlations between Agatston scores and Age, HD Age, PTH and CRP were significant. Delta increments of Agatston scores correlated also with serum calcium, CaxP, Fetuin-A, triglycerides and serum albumin. Logistic regression analysis showed Age, PTH and serum calcium as important predictors of Delta Agatston scores. LN transformation of the not normally distributed variables restricted the significant correlations to Age, BMI and CRP. Considering the Delta Agatston scores as dependent, significant predictors were Age, PTH and HDL. A strong association was found between basal calcification scores and Delta increment at one year. By logistic analysis, the one year increments in Agatston scores were found to be predictors of mortality. Diabetic and hypertensive patients have significantly higher Delta scores.ConclusionsProgression of calcification is of common occurrence, with special regard to elevated basal scores, and is predictive of survival. Higher predictive value of survival is linked to the one year increment of calcification scores. Some classic and non classic risk factors play an important role in progression. Some of them could be controlled with appropriate management with possible improvement of mortality.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM)

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.RiassuntoLa tomografia computerizzata del cuore (CCT) è diventata uno strumento efficace in differenti contesti clinici. Lo sviluppo della tecnologia ha portato ad una progressiva espansione delle indicazioni con una concomitante riduzione della dose di radiazioni necessaria per l’esecuzione dell’indagine. Ancora oggi sono pochi i documenti delle maggiori società scientifiche internazionali che si esprimono sulle effettive modalità di utilizzo e sulle indicazioni cliniche della CCT; in particolare mancano delle linee guida complete. Questo documento rispecchia la visione del gruppo di lavoro della Sezione di Cardio-Radiologia della Società Italiana di Radiologia Medica in merito alle indicazioni correnti della CCT.

Percutaneous vertebroplasty in painful schmorl nodes.

The Schmorl node represents displacement of intervertebral disc tissue into the vertebral body. Both Schmorl nodes and degenerative disc disease are common in the human spine. We performed a retrospective study, for the period from January 2003 to February 2005, evaluating 23 patients affected by painful Schmorl nodes, who underwent in our department percutaneous transpedicular injection of polymethylmethacrylate (vertebroplasty) in order to solve their back pain not responsive to medical and physical management. Eighteen patients reported improvement of the back pain and no one reported a worsening of symptoms. Improvement was swift and persistent in reducing symptoms. Painful Schmorl nodes, refractory to medical or physical therapy, should be considered as a new indication within those vertebral lesions adequately treatable utilizing Vertebroplasty procedure.

Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.RiassuntoLa risonanza magnetica cardiaca (RMC) è considerata oggi utile nella valutazione di numerose cardiopatie. Sulla base della nostra esperienza e di quanto già pubblicato in letteratura, abbiamo preparato un documento che si propone come strumento d’indirizzo all’uso clinico della RMC. In modo sintetico si descrivono le differenti cardiopatie e si esprime per ciascuna una classe di indicazione, da I a IV, in funzione della rilevanza delle informazioni diagnostiche aspettate.Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected. Riassunto

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the “one-step” technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37–81 years), was treated with a “one-step” percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Evaluation with 64-slice CT of the prevalence of coronary artery variants and congenital anomalies: a retrospective study of 3,236 patients

PurposeThis study retrospectively evaluated the prevalence of anatomical coronary artery variants and congenital anomalies in 3,236 patients imaged with 64-slice computed tomography (CT).Materials and methodsOver a period of 4 years, 3,236 patients underwent CT coronary angiography performed with the standard protocol. We assessed coronary artery dominance, presence of the intermediate branch, presence and number of diagonal and marginal branches and coronary anomalies subdivided into anomalies of origin and course, intrinsic anomalies and termination anomalies.ResultsCoronary dominance was right-sided in 88.1% of patients; the intermediate branch was present in 21.3%, the number of diagonal and marginal branches was one to two in >90%, and the number of coronary anomalies was 224 (89 of origin and course, 129 intrinsic anomalies and six termination anomalies).ConclusionsSixty-four-slice CT coronary angiography provides accurate three-dimensional evaluation of the coronary artery tree with correct visualisation of any coronary anomalies, a relatively common finding that had a prevalence of 5.7% in our study population.RiassuntoObiettivo o]Scopo del nostro lavoro è stato valutare con uno studio retrospettivo la prevalenza di varianti anatomiche ed anomalie coronariche in una popolazione di 3236 pazientiMateriali e metodiUn totale di 3236 pazienti è stato sottoposto a tomografia computerizzata (TC)-64 strati delle coronarie in 4 anni, utilizzando il protocollo standard. È stata valutata: la dominanza coronarica, la presenza del ramo intermedio, la presenza e il numero di rami diagonali e marginali, le anomalie coronariche (AC) suddividendole in anomalie di origine e decorso, intrinseche e di terminazione.RisultatiÈ stata riscontrata una dominanza destra nel 88,1% dei casi, il ramo intermedio nel 21,3%, la presenza di 1–2 rami diagonali e marginali in più del 90%, 224 AC (89 di origine e decorso, 129 intrinseche e 6 di terminazione).ConclusioniLa TC volumetrica consente un’accurata valutazione tridimensionale del circolo coronarico con visualizzazione delle anomalie coronariche che rappresentano un reperto relativamente comune nella popolazione con prevalenza del 5,7%.

Diagnostic accuracy of 64-slice CT in evaluating coronary artery bypass grafts and of the native coronary arteries

PurposeOur aim was to evaluate the accuracy, sensitivity and specificity of 64-slice multidetector computed tomography (MDCT) in the assessment of occlusions and stenoses of arterial and venous bypass grafts and disease progression in the native vessels distal to the graft, and to compare the results with those of conventional coronary angiography.Materials and methodsWe enrolled 78 individuals (45 men, 33 women; mean age 59) and evaluated 213 bypass grafts using a 64-slice MDCT scanner. All patients underwent conventional coronary angiography with a mean time interval between the two examinations of 2 days.ResultsOne patient was excluded due to arrhythmia during the examination. The 212 bypass grafts in the remaining 77 patients (98.7%) consisted of 115 (54%) venous grafts and 97 (46%) arterial grafts. In the 115 venous grafts, MDCT showed a sensitivity, specificity and accuracy of 100% in evaluating occluded grafts and a sensitivity of 94.4%, specificity of 98.4% and accuracy of 96.9% in evaluating significant stenoses. In evaluating occluded arterial grafts, sensitivity was 83.3%, specificity 100% and accuracy 98.9%, whereas in evaluating stenoses of arterial grafts, sensitivity was 100%, specificity 97.7% and accuracy 98%.ConclusionsSensitivity, specificity and accuracy in evaluating native coronary vessels distal to the graft allow for a complete assessment of the surgical and native circulation. The examination appears therefore to be exhaustive in ruling out or confirming the presence of diseased vessels in the postoperative follow-up.RiassuntoObiettivoScopo dello studio è valutare l’accuratezza diagnostica, la sensibilità e la specificità della tomografia computerizzata (TC) a 64 strati nella valutazione delle occlusioni e delle stenosi di bypass arteriosi e venosi e dell’eventuale progressione di malattia a carico dei vasi nativi distali all’anastomosi chirurgica, rapportando i risultati ottenuti con i reperti della coronarografia convenzionale (CC).Materiali e metodiSono stati sottoposti a studio con TC 64 strati 78 pazienti (45 maschi, 33 femmine; età media 59 anni) per un totale di 213 bypass (115 innesti venosi e 98 arteriosi). Tutti i pazienti sono andati incontro a CC dopo una media di 2 giorni.RisultatiUn paziente (1,3%) è stato escluso per l’insorgenza di un episodio aritmico durante l’esame. I 212 bypass presi in esame dei rimanenti 77 soggetti (98,7%), erano costituiti da 115 (54%) innesti venosi e 97 (46%) innesti arteriosi. Nei 115 by-pass venosi, la TC ha mostrato una sensibilità, una specificità ed una accuratezza diagnostica del 100% nella valutazione dei bypass occlusi e una sensibilità del 94,4%, una specificità del 98,4% ed un’accuratezza diagnostica del 96,9% nella valutazione delle stenosi significative. Nei bypass arteriosi occlusi, la sensibilità è stata dell’83,3%, la specificità del 100% e l’accuratezza diagnostica del 98,9%, mentre nelle stenosi dei bypass arteriosi, la sensibilità è stata del 100%, la specificità del 97,7% e l’accuratezza diagnostica del 98%.ConclusioniCome dimostrato dai risultati ottenuti, la correttezza delle informazioni fornite dalla TC si avvicina a quelle della CC consentendo una completa valutazione del circolo chirurgico e nativo e risultando completamente esaustivo nell’escludere o confermare la presenza di patologia vasale nel follow-up post-operatorio.

Individual patient data meta-analysis for the clinical assessment of coronary computed tomography angiography: protocol of the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT)

BackgroundCoronary computed tomography angiography has become the foremost noninvasive imaging modality of the coronary arteries and is used as an alternative to the reference standard, conventional coronary angiography, for direct visualization and detection of coronary artery stenoses in patients with suspected coronary artery disease. Nevertheless, there is considerable debate regarding the optimal target population to maximize clinical performance and patient benefit. The most obvious indication for noninvasive coronary computed tomography angiography in patients with suspected coronary artery disease would be to reliably exclude significant stenosis and, thus, avoid unnecessary invasive conventional coronary angiography. To do this, a test should have, at clinically appropriate pretest likelihoods, minimal false-negative outcomes resulting in a high negative predictive value. However, little is known about the influence of patient characteristics on the clinical predictive values of coronary computed tomography angiography. Previous regular systematic reviews and meta-analyses had to rely on limited summary patient cohort data offered by primary studies. Performing an individual patient data meta-analysis will enable a much more detailed and powerful analysis and thus increase representativeness and generalizability of the results. The individual patient data meta-analysis is registered with the PROSPERO database (CoMe-CCT, CRD42012002780).Methods/DesignThe analysis will include individual patient data from published and unpublished prospective diagnostic accuracy studies comparing coronary computed tomography angiography with conventional coronary angiography. These studies will be identified performing a systematic search in several electronic databases. Corresponding authors will be contacted and asked to provide obligatory and additional data. Risk factors, previous test results and symptoms of individual patients will be used to estimate the pretest likelihood of coronary artery disease. A bivariate random-effects model will be used to calculate pooled mean negative and positive predictive values as well as sensitivity and specificity. The primary outcome of interest will be positive and negative predictive values of coronary computed tomography angiography for the presence of coronary artery disease as a function of pretest likelihood of coronary artery disease, analyzed by meta-regression. As a secondary endpoint, factors that may influence the diagnostic performance and clinical value of computed tomography, such as heart rate and body mass index of patients, number of detector rows, and administration of beta blockade and nitroglycerin, will be investigated by integrating them as further covariates into the bivariate random-effects model.DiscussionThis collaborative individual patient data meta-analysis should provide answers to the pivotal question of which patients benefit most from noninvasive coronary computed tomography angiography and thus help to adequately select the right patients for this test.

Italian registry of cardiac magnetic resonance

OBJECTIVES Forty sites were involved in this multicenter and multivendor registry, which sought to evaluate indications, spectrum of protocols, impact on clinical decision making and safety profile of cardiac magnetic resonance (CMR). MATERIALS AND METHODS Data were prospectively collected on a 6-month period and included 3376 patients (47.2 ± 19 years; range 1-92 years). Recruited centers were asked to complete a preliminary general report followed by a single form/patient. Referral physicians were not required to exhibit any specific certificate of competency in CMR imaging. RESULTS Exams were performed with 1.5T scanners in 96% of cases followed by 3T (3%) and 1T (1%) magnets and contrast was administered in 84% of cases. The majority of cases were performed for the workup of inflammatory heart disease/cardiomyopathies representing overall 55.7% of exams followed by the assessment of myocardial viability and acute infarction (respectively 6.9% and 5.9% of patients). In 49% of cases the final diagnosis provided was considered relevant and with impact on patients clinical/therapeutic management. Safety evaluation revealed 30 (0.88%) clinical events, most of which due to patients preexisting conditions. Radiological reporting was recorded in 73% of exams. CONCLUSIONS CMR is performed in a large number of centers in Italy with relevant impact on clinical decision making and high safety profile.