Benussi P

Two-dimensional echocardiography in the diagnosis of intracardiac masses: a prospective study with anatomic validation

The accuracy of two-dimensional echocardiography in the detection of intracardiac masses was verified in 334 patients who underwent cardiac catheterization in our laboratory over 21 consecutive months. A complete two-dimensional echocardiographic (2DE) examination was performed a day before catheterization. The presence or absence of a mass was verified at surgery in 77 patients who successively underwent mitral or aortic valve replacement (51), left ventricular aneurysmectomy with or without myocardial revascularization (25), and resection of atrial myxoma (2). In 32 patients 2DE revealed the presence of a mass-left or right atrial thrombi in 12, left atrial myxoma in 2, left ventricular thrombi in 16, and endocardial vegetations in 2. The other 45 patients were free of intracardiac masses on 2DE. Anatomic verification at surgery revealed the presence of an intracardiac mass in 34 patients. In 30 (true positives) of these, 2DE revealed the mass as well, and in 4 (false negatives) the presence of a mass had not been identified by 2DE. In 2 patients (false positives) the predicted mass was not found at surgery. Absence of a mass was correctly predicted by 2DE in 41 patients (true negatives). Thus 2DE detected intracardiac masses with sensitivity of 88.2% and a specificity of 95.3%. We recommend that 2DE be performed in all patients prior to hemodynamic study and/or cardiac surgery to enable safer management of patients with intracardiac masses during cardiac catheterization and/or cardiac surgery.

Choice strategy of different dose-saving protocols in 64-slice MDCT coronary angiography.

PurposeMultidetector-row computed tomography coronary angiography (MDCT-CA) produces high-level radiation dose because of submillimetre slice thickness and short scan time. As a result, manufacturers have produced different dose-saving protocols that may, however, reduce image quality and thus diagnostic accuracy. The aim of our study was to assess the diagnostic quality of MDCT-CA using different dose-saving protocols.Materials and methodsBetween April and August 2008, we examined 65 patients with 64-slice MDCT-CA: 6/65 using the step-and-shoot dose-saving protocol, 45/65 the cardiac dose right protocol and 14/65 using a standard protocol. Image quality was evaluated on a per-patient and per-segment basis, and the effective dose of each protocol was recorded.ResultsIn the per-patient analysis, image quality was excellent in 100% of the step-and-shoot protocols, in 91.1% of the cardiac dose right protocols and in 85.8% of the standard protocols. Effective dose to the patient considering the whole study (i.e. scout, calcium score, triggering and MDCT-CA) was 20.49 mSv in the standard protocol, 14.8 mSv in the cardiac dose right protocol and 6.63 mSv in the step-and-shoot protocol.ConclusionsThe radiologist should apply the appropriate protocol in relation to the clinical indications, type of patient and information required in order to spare as much dose as possible while maintaining high image quality.RiassuntoIntroduzioneL’angiografia coronarica con tomografia computerizzata multistrato (AC-TCMS) comporta una dose elevata a causa di spessori submillimetrici e ridotti tempi di acquisizione; le case costruttrici quindi hanno prodotto protocolli di risparmio di dose che però possono ridurre la qualità delle immagini e l’accuratezza diagnostica. Lo scopo di questo lavoro è valutare la qualità diagnostica nello studio delle arterie coronarie con i differenti protocolli di risparmio di dose.Materiali e metodiTra aprile e agosto 2008, 65 pazienti sono stati sottoposti ad AC-TCMS a 64 detettori; 6/65 mediante protocollo step and shoot, 45/65 con protocollo cardiac dose right, 14/65 con protocollo standard. È stata valutata la qualità delle immagini con analisi per paziente e per segmento ed è stata calcolata la dose effettiva per ciascun protocollo di acquisizione.RisultatiNelle analisi per paziente la qualità delle immagini è risultata ottimale nel 100% dei casi per il protocollo step and shoot, nel 91,1% dei casi per il protocollo cardiac dose right e nell’85,8% dei casi per il protocollo standard. La dose effettiva al paziente dell’intero esame (calcium score e AC-TCMS) è risultata pari a 20,49 mSv nel protocollo standard, 14,8 mSv nel protocollo cardiac dose right e 6,63 mSv per il protocollo step and shoot.ConclusioniIl radiologo deve utilizzare il protocollo di scansione più adatto a seconda dell’indicazione clinica, del paziente e del tipo di informazioni necessarie per l’iter diagnostico.

Anatomical variants and anomalies of the coronary tree studied with MDCT coronary angiography

Anomalies of the coronary arteries are congenital and in most of the cases asymptomatic, although they may present with severe symptoms such as angina pectoris or cardiac arrest. Multidetector CT coronary angiography (MDCT-CA) permits, through curved multiplanar reconstructions and three-dimensional reformatting, noninvasive visualisation of the coronary tree and its variants and anomalies, providing a more accurate alternative to conventional coronary angiography (CCA). The purpose of this pictorial essay is to describe the main variants and anomalies of the coronary arteries using MDCT imaging with multiplanar and three-dimensional reconstructions.RiassuntoLe anomalie delle arterie coronariche sono presenti alla nascita nella maggior parte dei casi asintomatiche ma possono manifestarsi con sintomatologia severa quale angina pectoris o addirittura l’arresto cardiaco. L’angiografia coronarica mediante tomografia computerizzata multistrato (TCMS) permette, tramite ricostruzioni multiplanari secondo piani curvilinei e riformattazioni 3D, la visualizzazione dell’albero coronarico e delle sue varianti ed anomalie in maniera non invasiva, fornendo migliore e più accurata alternativa alla angiografia coronarica (AC). Lo scopo di questo pictorial consiste nella descrizione mediante immagini TCMS con ricostruzioni multiplanari e 3D delle principali varianti e anomalie delle arterie coronarie.

Diagnostic accuracy in coronary stenosis: comparison between visual score and quantitative analysis (quantitative computed tomographic angiography) in coronary angiography by multidetector computed tomography-coronary angiography and quantitative analysis (quantitative coronary angiography) in conventional coronary angiography.

Background: Multidetector computed tomography-coronary angiography allows quantification of coronary stenosis with a high level of accuracy; however, the inherent inaccuracy of visual score still remains. Computed quantitative vessel analysis systems (quantitative computed tomographic angiography [QCTA]) aim to overcome this limitation. The aim of our study was to evaluate the accuracy of QCTA in comparison with quantitative coronary angiography (QCA) and visual score using the QCA. Materials and Methods: Two operators visually scored 30 consecutive patients referred for multidetector computed tomography-coronary angiography to assess stenotic segments according to a modified 17-segment American Heart Association classification model. Coronary angiography was performed within 1 week. The degree of stenosis was classified as 0%, lower than 20% (wall irregularities), lower than 50% (without significant disease), and higher than 50% (significant disease). Each segment was then analyzed using electronic calipers of the QCTA system. Data were compared with QCA results. Each segment was finally classified as fibrofatty, mixed, and calcified. Comparisons between QCTA results, visual score, and QCA were performed by means of Spearman rank correlation. Interobserver variability is calculated using &kgr; statistics. Results: From a total of 870 segments, 69 were diseased. Interobserver agreement between the 2 operators resulted very high (&kgr; = 0.97). A good correlation was found between visual score and QCA (&rgr; = 0.932, P < 0.0001) and between visual score and QCTA (&rgr; = 0.845, P < 0.0001). A moderate correlation was found between QCTA and QCA (&rgr; = 0.810, P < 0.0001). Conclusions: The accuracy of QCTA is comparable with that of QCA and visual score especially in noncalcified vessels. Editing of the vessel contours in case of calcified vessels is helpful in correctly estimating the right percentage of stenosis.

MDCT coronary angiography vs 2D echocardiography for the assessment of left ventricle functional parameters

PurposeThis study was done to compare the parameters of left ventricular (LV) function obtained by multidetector computed tomography coronary angiography (MDCT-CA) using 64-slice equipment with those obtained using twodimensional echocardiography (2D-SE) considered as reference standard.Materials and methodsBetween April 2008 and September 2009, 116 consecutive patients were studied with both techniques. We analysed the parameters commonly sampled in echocardiography and related them with those retrieved with MDCT-CA: septal thickness, posterior wall thickness, diameter of ascending aorta, diameter and volumes in end-systolic and end-diastolic phase, ejection fraction, stroke volume, cardiac output and heart mass.ResultsGood correlation was found measuring septal thickness (r=0.470; p=0.001), and diameters of the ascending aorta. Correlation between systolic and diastolic diameters obtained with the two techniques was good. Poor correlation was attained measuring thickness of the posterior wall (r=0.243; p=0.104). MDCT-CA consistently overestimated the average volumes; diastolic and systolic volumes showed significant correlation (r=0.0456; p= 0.002; r=0.640; p<0.001). Ejection fraction agreement showed a significant correlation (r=0.626; p<0.001).ConclusionsMDCT-CA provides parameters of cardiac function comparable to those found in echocardiography. MDCT-CA although used primarily for coronary noninvasive imaging can provide additional information on ventricular function useful to the diagnostic workup of cardiac patients.RiassuntoObiettivoScopo del nostro studio è stato comparare i parametri della funzione ventricolare ottenuti mediante angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) a 64 strati con quelli ottenuti mediante ecocardiografia bidimensionale (2DSE), considerata come standard di riferimento.Materiali e metodiTra aprile 2008 e settembre 2009, 116 pazienti consecutivi sono stati studiati con entrambe le tecniche. Sono stati analizzati per entrambe le metodiche i seguenti parametri comunemente campionati in ecocardiografia e correlati con quelli ottenuti in ACTCMS: spessore del setto, spessore della parete posteriore, diametro dell’aorta ascendente, diametro e volume tele sistolico e tele diastolico, frazione di eiezione, stroke volume, gittata cardiaca e massa cardiaca.RisultatiÈ stata riscontrata una buona correlazione tra le misure dello spessore del setto (r=0,470 e p=0,001) e del diametro dell’aorta ascendente (r=0,777 e p<0,001) in ecografia e in TC, mentre una scarsa correlazione tra le misure dello spessore della parete posteriore (r=0,243 e p=0,104). La correlazione tra i diametri tele diastolico (r=0,375 e p=0,054) e tele sistolico (r=0,703 e p<0,001) ottenuti con le due tecniche è risultata buona. La TCMS ha sovrastimato in modo consistente i valori medi dei volumi rispetto all’ecocardiografia ma i volumi tele diastolico e tele sistolico derivati dalla 2DSE e dalla ACTCMS hanno mostrato una correlazione significativa (rispettivamente r=0,456 e p=0,002; r=0,640 e p<0,001). Come indicatore di funzione sistolica globale del ventricolo sinistro (VS), la frazione di eiezione (FE) misurata tramite TCMS o ecocardiografia ha mostrato un’eccellente correlazione (r=0,626 e p<0,001).ConclusioniLa AC-TCMS fornisce parametri della funzione cardiaca comparabili a quelli riscontrati in ecocardiografia. La AC-TCMS sebbene utilizzata prevalentemente per l’imaging non invasivo delle arterie coronarie, può fornire informazioni aggiuntive allo studio delle coronarie utili al work up diagnostico dei pazienti con patologie coronariche e cardiache.

Role of coronary angiography MDCT in the clinical setting: changes in diagnostic workup in the real world.

PurposeThe authors sought to evaluate the incremental value of introducing coronary angiography with multidetector computed tomography (MDCT-CA) compared with the conventional diagnostic workup in managing patients with suspected coronary artery disease (CAD) workup.Materials and methodsA total of 531 consecutive patients underwent MDCT-CA between April 2008 and August 2010. For each patient the pretest probability of CAD was obtained by using the Morise score as well as the diagnostic performance of the exercise test and of MDCT-CA, considering conventional coronary angiography (CCA) as the gold standard. Based on these results, we calculated the posttest likelihood of CAD after stress testing, comparing the incremental diagnostic value for each category of cardiovascular risk with data obtained with MDCT-CA. The conventional diagnostic workup (without MDCT-CA) was then compared with the modified workup (including MDCT-CA).ResultsThe diagnostic performance of the exercise test for identifying patients with significant lesions had a sensitivity and specificity of 20% and 88%, respectively, with positive (PPV) and negative (NPV) predictive value of 41% and 72%, respectively. Taking CA as the gold standard, MDCT-CA had 93% sensitivity, 89% specificity, 88% PPV and 93% NPV compared with CCA in evaluating significant stenoses in the per-patient analysis. The overall diagnostic accuracy of MDCT-CA was 91%. The exercise tests provided no significant incremental diagnostic value compared with cardiovascular history in patients with a low to intermediate risk. Comparison of the diagnostic accuracy of these protocols showed improved performance results for the modified protocol.ConclusionsMDCT-CA is the reference modality for the noninvasive exclusion of critical CAD. It provides a very high incremental diagnostic value compared with exercise testing in patients with a low to intermediate risk of CAD. The use of diagnostic protocols based on MDCT-CA ensures improved diagnostic performance compared with those involving conventional exercise electrocardiograms.RiassuntoObiettivoScopo del nostro lavoro è valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia assiale multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico.Materiali e metodiSono stati presi in considerazione 531 pazienti consecutivi sottoposti ad AC-TCMS tra marzo 2008 e agosto 2010. Per ogni paziente è stato calcolata la probabilità pre-test di CAD mediante Morise score e la performance diagnostica del cicloergometro e della ACTCMS considerando l’AC come standard di riferimento; Sulla base dei risultati è stata calcolata la probabilità post-test di CAD dopo stress test, confrontandone il valore diagnostico incrementale per ogni categoria di rischio cardiovascolare con i dati ottenuti dalla AC-TCMS. è stato confrontato il percorso diagnostico tradizionale senza ACTCMS, con quello modificato dall’introduzione dell’ACTCMS.RisultatiLa performance diagnostica dello stress test nella individuazione dei pazienti con lesioni significative ha dimostrato una sensibilità e specificità del 20% e 88% con valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 41% e 72%. Considerando come standard di riferimento la AC il confronto tra AC e ACTCMS nella valutazione di stenosi significative mediante analisi per paziente ha rilevato una sensibilità pari a 93%, una specificità pari a 89%, un VPP e VPN pari a 88 % e 93%. L’accuratezza diagnostica globale della metodica è risultata essere pari a 91%. Lo stress test ha dimostrato di non fornire un significativo valore diagnostico incrementale rispetto all’anamnesi cardiovascolare nei pazienti a basso-medio rischio. Il confronto tra l’accuratezza diagnostica dei protocolli ha dimostrato una migliore performance del protocollo che prevede l’introduzione dell’ACTCMS nei confronti del protocollo tradizionale.ConclusioniLa AC-TCMS è una metodica di riferimento non invasiva per l’esclusione di coronaropatia critica. Fornisce un valore diagnostico incrementale molto elevato rispetto allo stress test nei pazienti a basso-medio rischio. L’utilizzazione del protocollo diagnostico che prevede l’utilizzo dell’AC-TCMS garantisce una migliore perfomance diagnostica rispetto al protocollo tradizionale.

Direct visualization of aorto-coronary bypass grafts by two-dimensional echocardiography: A new clinical application

An attempt was made to assess noninvasively the patency of aorto-coronary bypass grafts by two-dimensional echocardiography (2-D echo) in 21 patients who underwent myocardial revascularization. Fifteen patients had one graft while the other six had two grafts. All 21 patients underwent angiography 6–18 months after operation. A day before angiography a 2-D echo was performed with the aim of visualizing the bypass grafts. In 18 patients with 23 grafts (13 with 1 graft and 5 with 2 grafts) it was possible to visualize the tract of the graft, by 2-D echo; 16 were judged patent on 2-D echo and confirmed by selective angiography, while 5 grafts were considered occluded both on 2-D echo and angiography. The other 2 grafts were considered to be occluded on 2-D echo but angiographic control displayed their patency. In 3 patients 2-D echo failed to visualize grafts that were patent angiographically. These data must be considered preliminary and need validation in a larger number of patients. However it is reasonable to conclude that 2-D echo has a reliable capacity to predict graft patency. Such an application may be of value in sequential control of patients with aorto-coronary bypass surgery, especially when combined with other clinical and/or technical data.