Darra Murphy

Mitral Annular Dimensions and Geometry in Patients With Functional Mitral Regurgitation and Mitral Valve Prolapse : Implications for Transcatheter Mitral Valve Implantation

OBJECTIVES The aims of this study were to determine D-shaped mitral annulus (MA) dimensions in control subjects without significant cardiac disease and in patients with moderate to severe mitral regurgitation (MR) being considered for transcatheter mitral therapy and to determine predictors of annular size, using cardiac computed tomography. BACKGROUND The recently introduced D-shaped method of MA segmentation represents a biomechanically appropriate approach for annular sizing prior to transcatheter mitral valve implantation. METHODS Patients who had retrospectively gated cardiac computed tomography performed at our institution (2012 to 2014) and were free of significant cardiac disease were included as controls (n = 88; 56 ± 11 years of age; 47% female) and were compared with patients with moderate or severe MR due to functional mitral regurgitation (FMR) (n = 27) or mitral valve prolapse (MVP) (n = 32). MA dimensions (projected area, perimeter, intercommissural, and septal-to-lateral distance), maximal left atrial (LA) volumes, and phasic left ventricular volumes were measured. RESULTS MA dimensions were larger in patients with FMR or MVP compared with controls (area index 4.7 ± 0.6 cm(2)/m(2), 6.0 ± 1.3 cm(2)/m(2), and 7.3 ± 1.7 cm(2)/m(2); perimeter index 59 ± 5 mm/m(2), 67 ± 9 mm/m(2), and 75 ± 10 mm/m(2); intercommissural distance index 20.2 ± 1.9 mm/m(2), 21.2 ± 3.1 mm/m(2), and 24.7 ± 3.2 mm/m(2); septal-to-lateral distance index 14.8 ± 1.6, 18.1 ± 3.3, and 19.5 ± 3.4 mm/m(2) in controls and patients with FMR and MVP, respectively; p < 0.05 between controls and MR subgroups). Absolute MA area was 18% larger in patients with MVP than patients with FMR (13.0 ± 2.9 cm(2) vs. 11.0 ± 2.3 cm(2); p = 0.006). Although LA and left ventricular volumes were both independently associated with MA area index in controls and patients with MVP, only LA volume was associated with annular size in patients with FMR. CONCLUSIONS Moderate to severe MR was associated with increased MA dimensions, especially among patients with MVP compared with control subjects without cardiac disease. Moreover, unlike in controls and patients with MVP, annular enlargement in FMR was more closely associated with LA dilation.

Predicting Mortality in Systemic Sclerosis-Associated Interstitial Lung Disease Using Risk Prediction Models Derived From Idiopathic Pulmonary Fibrosis

BACKGROUND Mortality risk prediction tools have been developed in idiopathic pulmonary fibrosis, however, it is unknown whether these models accurately estimate mortality in systemic sclerosis-associated interstitial lung disease (SSc-ILD). METHODS Four baseline risk prediction models--the Composite Physiologic Index, the Interstitial Lung Disease-Gender, Age, Physiology Index, the du Bois index, and the modified du Bois index--were calculated for patients recruited from a specialized SSc-ILD clinic. Each baseline model was assessed using logistic regression analysis with 1-year mortality as the outcome variable. Discrimination was quantified using the area under the receiver operating characteristic curve. Calibration was assessed using the goodness-of-fit test. The incremental prognostic ability of additional predictor variables was determined by adding prespecified variables to each baseline model. RESULTS The 156 patients with SSc-ILD completed 1,294 pulmonary function tests, 725 6-min walk tests, and 637 echocardiograms. Median survival was 15.0 years from the time of SSc-ILD diagnosis. All baseline models were significant predictors of 1-year mortality in SSc-ILD. The modified du Bois index had an area under the receiver operating characteristic curve of 0.84, compared with 0.77 to 0.81 in the other models. Calibration was acceptable for the modified du Bois index, but was poor for the other models. All baseline models include FVC and 6-min walk distance was identified as an additional independent predictor of 1-year mortality. CONCLUSIONS The modified du Bois index has good discrimination and calibration for the prediction of 1-year mortality in SSc-ILD. FVC and 6-min walk distance are important independent predictors of 1-year mortality in SSc-ILD.

Cough is less common and less severe in systemic sclerosis-associated interstitial lung disease compared to other fibrotic interstitial lung diseases

The objectives of this study were to determine the prevalence and characteristics of cough in idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis (HP) and systemic sclerosis‐associated interstitial lung disease (SSc‐ILD).

Pulmonary hamartomas: CT pixel analysis for fat attenuation using radiologic–pathologic correlation

To assess the accuracy of CT pixel analysis for fat attenuation in pulmonary hamartomas.

Phenotyping COPD exacerbations using imaging and blood-based biomarkers

Rationale Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are caused by a variety of different etiologic agents. Our aim was to phenotype COPD exacerbations using imaging (chest X-ray [CXR] and computed tomography [CT]) and to determine the possible role of the blood tests (C-reactive protein [CRP], the N-terminal prohormone brain natriuretic peptide [NT-proBNP]) as diagnostic biomarkers. Materials and methods Subjects who were hospitalized with a primary diagnosis of AECOPD and who had had CXRs, CT scans, and blood collection for CRP and NT-proBNP were assessed in this study. Radiologist blinded to the clinical and laboratory characteristics of the subjects interpreted their CXRs and CT images. ANOVA and Spearman’s correlation were performed to test for associations between these imaging parameters and the blood-based biomarkers NT-proBNP and CRP; logistic regression models were used to assess the performance of these biomarkers in predicting the radiological parameters. Results A total of 309 subjects were examined for this study. Subjects had a mean age of 65.6±11.1 years, 66.7% of them were males, and 62.4% were current smokers, with a mean FEV1 54.4%±21.5% of predicted. Blood NT-proBNP concentrations were associated with cardiac enlargement (area under the curve [AUC] =0.72, P<0.001), pulmonary edema (AUC =0.63, P=0.009), and pleural effusion on CXR (AUC =0.64, P=0.01); whereas on CT images, NT-proBNP concentrations were associated with pleural effusion (AUC =0.71, P=0.002). Serum CRP concentrations, on the other hand, were associated with consolidation on CT images (AUC =0.75, P<0.001), ground glass opacities (AUC =0.64, P=0.028), and pleural effusion (AUC =0.72, P<0.001) on CT images. A serum CRP sensitivity-oriented cutoff point of 11.5 mg/L was selected for the presence of consolidation on CT images in subjects admitted as cases of AECOPD, which has a sensitivity of 91% and a specificity of 53% (P<0.001). Conclusion Elevated CRP may indicate the presence of pneumonia, while elevated NT-proBNP may indicate cardiac dysfunction. These readily available blood-based biomarkers may provide more accurate phenotyping of AECOPD and enable the discovery of more precise therapies.

Comparison of low-dose coronary artery calcium scoring using low tube current technique and hybrid iterative reconstruction vs. filtered back projection

INTRODUCTION We sought to validate whether low dose CACS CT with hybrid IR (HIR) could replace standard dose filtered back projection (FBP). METHOD We enrolled 100 patients to undergo low dose CACS CT with HIR, in addition to routine full dose FBP. RESULTS No significant difference between full and low dose CT in Agatston score 138.2±360.6 vs. 137.3±356.4 (p=0.272) or calcium mass score 19±48.3 vs. 18.7±49 (p=0.8), respectively. Bland-Altman analysis showed no systematic bias. Calcium volume difference was statistically significant 57.2±134 vs. 55.1±130.2 (p=0.001). CONCLUSION Low dose CT for calcium scoring with HIR enables stable CACS Agatston score and calcium mass quantification as compared to full dose FBP.

Oesophageal diameter is associated with severity but not progression of systemic sclerosis-associated interstitial lung disease: Oesophageal diameter and SSc-ILD severity

It is unknown whether oesophageal disease is associated with systemic sclerosis‐associated interstitial lung disease (SSc‐ILD) severity, progression or mortality.

Recurrent pneumothorax related to diffuse dendriform pulmonary ossification in genetically predisposed individual.

Diffuse pulmonary ossification (DPO) is a rare disease with unknown pathogenesis, clinical manifestations, and treatment options. This report describes the diagnosis of DPO in an otherwise healthy 26‐year‐old man with recurrent spontaneous pneumothorax. His father was diagnosed with a similar lung condition in his 30s with computed tomography (CT) images that were strikingly similar to those of the patient. This report suggests that DPO can induce spontaneous pneumothorax and its pathogenesis may have a possible genetic predisposition that needs further research.

Hypertrophic Cardiomyopathy (HCM): New insights into Coronary artery remodelling and ischemia from FFRCT

INTRODUCTION Angina, myocardial ischemia, and coronary artery physiology in hypertrophic cardiomyopathy (HCM) are poorly understood. However, coronary computed tomography angiography (CCTA) with fractional flow reserve from CT (FFRCT) analysis offers a non-invasive method for evaluation of coronary artery volume to myocardial mass ratio (V/M) that may provide insight into such mechanisms. Thus, we sought to investigate changes in V/M in HCM. METHODS A retrospective analysis was performed on 37 HCM patients and 37 controls matched for age, sex, and cardiovascular risk factors; CCTA-derived coronary artery lumen volume (V) and myocardial mass (M) were used to determine V/M. FFRCT values were calculated for the left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA) arteries as well as the 3-vessel cumulative FFRCT values. RESULTS HCM patients had significantly increased myocardial mass (176 ± 84 vs. 119 ± 27 g, p < 0.0001) and total coronary artery luminal volume (4112 ± 1139 vs. 3290 ± 924 mm3, p < 0.0001) that resulted from increases in segmented luminal volumes of both the left and right coronary artery systems. However, HCM patients had significantly decreased V/M (23.8 ± 5.9 vs. 26.5 ± 5.3 mm3/g; p = 0.026) which was further decreased when restricting V/M analysis to those HCM patients with septal hypertrophy (22.4 mm3/g, p = 0.01) that was mild-moderately predictive of HCM (AUC = 0.68). HCM patients also showed significantly lower nadir FFRCT values in the LCx (0.87 ± 0.06 vs. 0.91 ± 0.06, p = 0.02), and cumulative 3-vessel FFRCT values (2.58 ± 0.18 vs. 2.63 ± 0.14, p = 0.006). CONCLUSIONS HCM patients demonstrate significantly greater coronary volume. Despite this, HCM patients suffer from decreased V/M. Further prospective studies evaluating the relationship between V/M, angina, and heart failure in HCM are needed.

Indexed Aortic Area in Bicuspid Valve Disease: An Important Step Toward a More Personalized Approach to Risk Prediction and Clinical Decision Making

> Never put off until tomorrow what you can do the day after tomorrow . > > —Mark Twain The decision to undertake thoracic aortic repair in patients with progressive aortic dilation in the setting of bicuspid aortic valvular disease remains a point of much discussion and continuing investigation. The ongoing work to find an optimal cutoff value for intervention that balances surgical risk and risk of dissection or rupture to optimize patient care is perhaps best reflected in the most recent American College of Cardiology/ American Heart Association guidelines (2014) that recommended a 5.5 cm threshold for surgery in regard to patients with bicuspid valves.1 This is a notable change from the 2010 guidelines which cited a 5 cm threshold.2 These thresholds have informed clinical decisions for decades but are inherently limited because they do not adjust for patient size (body surface area or height) or sex. Growing awareness of the limitations of unadjusted 2-dimensional measurements of the aorta has driven a desire …