Federico Cesarani

Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation?: results from a multicenter study.

OBJECTIVESnThis study investigated the left atrial appendage (LAA) by computed tomography (CT) and magnetic resonance imaging (MRI) to categorize different LAA morphologies and to correlate the morphology with the history of stroke/transient ischemic attack (TIA).nnnBACKGROUNDnLAA represents one of the major sources of cardiac thrombus formation responsible for TIA/stroke in patients with atrial fibrillation (AF).nnnMETHODSnWe studied 932 patients with drug-refractory AF who were planning to undergo catheter ablation. All patients underwent cardiac CT or MRI of the LAA and were screened for history of TIA/stroke. Four different morphologies were used to categorize LAA: Cactus, Chicken Wing, Windsock, and Cauliflower.nnnRESULTSnCT scans of 499 patients and MRI scans of 433 patients were analyzed (age 59 ± 10 years, 79% were male, and 14% had CHADS(2) [Congestive heart failure, hypertension, Age >75, Diabetes mellitus, and prior stroke or transient ischemic attack] score ≥2). The distribution of different LAA morphologies was Cactus (278 [30%]), Chicken Wing (451 [48%]), Windsock (179 [19%]), and Cauliflower (24 [3%]). Of the 932 patients, 78 (8%) had a history of ischemic stroke or TIA. The prevalence of pre-procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies was 12%, 4%, 10%, and 18%, respectively (p = 0.003). After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be 79% less likely to have a stroke/TIA history (odd ratio: 0.21, 95% confidence interval: 0.05 to 0.91, p = 0.036). In a separate multivariate model, we entered Chicken Wing as the reference group and assessed the likelihood of stroke in other groups in relation to reference. Compared with chicken wing, cactus was 4.08 times (p = 0.046), Windsock was 4.5 times (p = 0.038), and Cauliflower was 8.0 times (p = 0.056) more likely to have had a stroke/TIA.nnnCONCLUSIONSnPatients with Chicken Wing LAA morphology are less likely to have an embolic event even after controlling for comorbidities and CHADS2 score. If confirmed, these results could have a relevant impact on the anticoagulation management of patients with a low-intermediate risk for stroke/TIA.

Radiofrequency catheter ablation of atrial fibrillation: A cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation

Background— Radiofrequency left atrial catheter ablation has become a routine procedure for treatment of atrial fibrillation. The aim of this study was to assess with preprocedural and postprocedural cerebral magnetic resonance imaging the thromboembolic risk, either silent or clinically manifest, in the context of atrial fibrillation ablation. The secondary end point was the identification of clinical or procedural parameters that correlate with cerebral embolism. Methods and Results— A total of 232 consecutive patients with paroxysmal or persistent atrial fibrillation who were candidates for radiofrequency left atrial catheter ablation were included in the study. Pulmonary vein isolation or pulmonary vein isolation plus linear lesions plus atrial defragmentation with the use of irrigated-tip ablation catheters was performed. All of the patients underwent preprocedural and postablation cerebral magnetic resonance imaging. A periprocedural symptomatic cerebrovascular accident occurred in 1 patient (0.4%). Postprocedural cerebral magnetic resonance imaging was positive for new embolic lesions in 33 patients (14%). No clinical parameters such as age, hypertension, diabetes mellitus, previous history of stroke, type of atrial fibrillation, and preablation antithrombotic treatment showed significant correlation with ischemic cerebral embolism. Procedural parameters such as activated clotting time value and, in particular, electric or pharmacological cardioversion to sinus rhythm correlated with an increased incidence of cerebral embolism. Cardioversion was also associated with an increased risk of 2.75 (95% confidence interval, 1.29 to 5.89; P=0.009). Conclusions— Radiofrequency left atrial catheter ablation carries a low risk of symptomatic cerebral ischemia but is associated with a substantial risk of silent cerebral ischemia detected on magnetic resonance imaging. Independent risk factors for cerebral thromboembolism are the level of activated clotting time and, in particular, the electric or pharmacological cardioversion to sinus rhythm during the procedure.

Prevalence of silent cerebral ischemia in paroxysmal and persistent atrial fibrillation and correlation with cognitive function.

OBJECTIVESnThe aim of this study was to compare the prevalence of silent cerebral ischemia (SCI) and cognitive performance in patients with paroxysmal and persistent atrial fibrillation (AF) and controls in sinus rhythm.nnnBACKGROUNDnLarge registries have reported a similar risk for symptomatic stroke in both paroxysmal and persistent AF. The relationship among paroxysmal and persistent AF, SCI, and cognitive impairment has remained uncharted.nnnMETHODSnTwo hundred seventy subjects were enrolled: 180 patients with AF (50% paroxysmal and 50% persistent) and 90 controls. All subjects underwent clinical assessment, neurological examination, cerebral magnetic resonance, and the Repeatable Battery for the Assessment of Neuropsychological Status.nnnRESULTSnAt least 1 area of SCI was present in 80 patients (89%) with paroxysmal AF, 83 (92%) with persistent AF (paroxysmal vs. persistent, p = 0.59), and 41 (46%) controls (paroxysmal vs. controls and persistent vs. controls, p < 0.01). The number of areas of SCI per subject was higher in patients with persistent AF than in those with paroxysmal AF (41.1 ± 28.0 vs. 33.2 ± 22.8, p = 0.04), with controls reporting lower figures (12.0 ± 26.7, p < 0.01 for both). Cognitive performance was significantly worse in patients with persistent and paroxysmal AF than in controls (Repeatable Battery for the Assessment of Neuropsychological Status scores 82.9 ± 11.5, 86.2 ± 13.8, and 92.4 ± 15.4 points, respectively, p < 0.01).nnnCONCLUSIONSnPatients with paroxysmal and persistent AF had a higher prevalence and number of areas of SCI per patient than controls and worse cognitive performance than subjects in sinus rhythm.

Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study

BACKGROUNDnSilent cerebral ischemia (SCI) has been reported in 14% of cases after catheter ablation of atrial fibrillation (AF) with radiofrequency (RF) energy and discontinuation of warfarin before AF ablation procedures.nnnOBJECTIVEnThe purpose of this study was to determine whether periprocedural anticoagulation management affects the incidence of SCI after RF ablation using an open irrigated catheter.nnnMETHODSnConsecutive patients undergoing RF ablation for AF without warfarin discontinuation and receiving heparin bolus before transseptal catheterization (group I, n = 146) were compared with a group of patients who had protocol deviation in terms of maintaining the therapeutic preprocedural international normalized ratio (patients with subtherapeutic INR) and/or failure to receive pretransseptal heparin bolus infusion and/or ≥2 consecutive ACT measurements <300 seconds (noncompliant population, group II, n = 134) and with a group of patients undergoing RF ablation with warfarin discontinuation bridged with low molecular weight heparin (group III, n = 148). All patients underwent preablation and postablation (within 48 hours) diffusion magnetic resonance imaging.nnnRESULTSnSCI was detected in 2% of patients (3/146) in group I, 7% (10/134) in group II, and 14% (21/148) in group III (P <.001). Therapeutic INR was strongly associated with a lower prevalence of postprocedural silent cerebral ischemia (SCI). Multivariable analysis demonstrated nonparoxysmal AF (odds ratio 3.8, 95% confidence interval 1.5-9.7, P = .005) and noncompliance to protocol (odds ratio 2.8, 95% confidence interval 1.5-5.1, P <.001] to be significant predictors of ischemic events.nnnCONCLUSIONnStrict adherence to an anticoagulation protocol significantly reduces the prevalence of SCI after catheter ablation of AF with RF energy.

The role of early radiological studies after gastric bariatric surgery.

Background: The authors investigated early radiological findings after gastric surgery for morbid obesity to evaluate their usefulness in avoiding complications or facilitating treatment. Material and Methods: 413 patients underwent gastric bariatric surgery: 327 had vertical banded gastroplasty (VBG), 55 Roux-en-Y gastric bypass (RYGBP), 22 adjustable silicone gastric banding (ASGB), and 9 biliopancreatic diversion (BPD). A radiological upper gastrointestinal investigation employing water-soluble contrast medium was perform ed in each patient between the 2nd and 8th postoperative day. Several techniques were employed to assess different radiological findings related to the anatomic modifications after the bariatric surgery. Results: In VBGs, delayed emptying was found in 10 patients (3%), gastric leak in 3 patients (0.9%), vertical suture breakdown in 1 patient (0.3%), and a wide pouch in 4 patients (1.2%). In RYGBP, a leak was detected in 2 patients (3.6%), delayed emptying in 2 (3.6%), and a wide pouch in 5 (9.1%). ASGB required band enlargement for stomal stenosis in 6 patients (27.2%). Temporary delayed emptying from stomal stenosis was also observed in 2 BPDs (22.2%). Overall complications were 35/413 (8.2%). Two cases of gastric leak after VBG were reoperated. Stomal stenosis after ASGB was treated by percutaneous band deflation; other cases were medically treated until complete healing. Conclusions: Early radiological study after gastric bariatric surgery is advisable, since it detected post operative complications (gastric perforation, stomal stenosis, etc.) and modified the clinical approach. As the interpretation of these radiographs is often difficult, involving different projections or patients positions or other technical managements, surgeons and radiologists must interact and be knowledgable.

Left atrial appendage morphology and silent cerebral ischemia in patients with atrial fibrillation

BACKGROUNDnLeft atrial appendage (LAA) is the major source of cardiac thrombi in atrial fibrillation (AF) and plays a major role in cardioembolic events.nnnOBJECTIVEnTo investigate the correlation between LAA morphology and the burden of silent cerebral ischemia (SCI) as a new thromboembolic risk marker in patients with AF.nnnMETHODSnA total of 348 patients with AF undergoing transcatheter ablation were enrolled. A cerebral magnetic resonance (MR) was performed to assess SCI burden, while LAA morphology was studied by MR or computed tomography and categorized as follows: cactus in 52 (14.9%) patients, chicken wing in 177 (50.9%), wind sock in 101 (29.0%), and cauliflower in 18 (5.2%).nnnRESULTSnSCIs were detected in 295 (84.8%) patients, with a median number of lesions of 23. SCI burden was related to LAA complexity: 30.8% and 17.3% patients with cactus, 30.5% and 22.0% with chicken wing, 13.9% and 27.7% with wind sock, and 16.7% and 38.9% with cauliflower LAA morphologies were in the first and fourth quartiles of number of SCI per patient, respectively (P = .035). After adjustment for potential confounders, only age (β 0.12; 95% CI 0.08-0.16; P < .001), chicken wing (β -0.28; 95% CI -0.51 to -0.04; P = .021), wind sock (β 0.38; 95% CI 0.12-0.65; P = .005), and cauliflower (β 0.61; 95% CI 0.07-1.14; P = .026) LAA morphologies were significantly related to SCI burden.nnnCONCLUSIONnLAA morphology relates to the burden of SCI in AF patients. Future research should corroborate if accessible methods (eg, echocardiography) are able to describe LAA morphology, permitting its use within universal thromboembolic risk predictors in AF patients.

Role of Interventional Radiology in the Treatment of Biliary Strictures Following Orthotopic Liver Transplantation

AbstractPurpose: To evaluate the efficacy andnsafety of percutaneous treatment of biliary strictures complicatingnorthotopic liver transplantation (OLT).nMethods: BetweennOctober 1990 and May 2000, 619 patients underwent 678 liverntransplants. Seventy of the 619 (11%) patients were found to benaffected by biliary strictures by July 2000. Bilioplasty was performednin 51 of these 70 (73%) patients. A cohort of 33 of 51 (65%) patientsnwere clinically followed for more than 12 months after the lastnpercutaneous treatment and included in the survey results.nResults: After one to three treatments 24 of 33 (73%)npatients were stricture-free on ultrasound and MR cholangiographynfollow-up. A delayed stricture recurrence required a fourthnpercutaneous bilioplasty in two of 33 (6%) patients. A surgicalnbilioenteric anastomosis was performed in six of 33 (18%) patients.nRetransplantation was performed due to ischemic damage in one of 33n(3%) patients.nConclusion: Interventional radiology isnan effective therapeutic alternative for the treatment of most biliarynstrictures complicating OLT. It has a high success rate and should benconsidered before surgical interventions. Elective surgery may bennecessary in a few failed cases or those with more severe and extensivenbiliary strictures.n

Scenes from the past: multidetector CT study of gallbladder stones in a wrapped Egyptian mummy.

A whole-body examination was performed with multidetector computed tomography (CT) of a completely wrapped Egyptian mummy from the collection at the Egyptian Museum in Turin, Italy. The mummy dates from the Eighteenth Dynasty. Although embalmment of the deceased man should have included evisceration in accordance with his social rank, no canopic jars containing internal organs had been found at the discovery of his tomb, and at CT, all the organs were found to have desiccated inside the body. Numerous calcified stones that were incidentally identified in the gallbladder had attenuation characteristics indicative of a predominant bile pigment content. This case demonstrates the superior capabilities of multidetector CT for the noninvasive study of embalmed bodies. The intrinsic capacity of CT for depicting the density of materials allowed not only the identification of the gallbladder stones but also their characterization.

Rest perfusion abnormalities in hypertrophic cardiomyopathy: correlation with myocardial fibrosis and risk factors for sudden cardiac death

Aim To measure the prevalence of abnormal rest perfusion in a population of consecutive patients with known hypertrophic cardiomyopathy (HCM) referred for cardiovascular MRI (CMR), and to assess any associations between abnormal rest perfusion and the presence, pattern, and severity of myocardial scar and the presence of risk factors for sudden death. Materials and methods Eighty consecutive patients with known HCM referred for CMR underwent functional imaging, rest first-pass perfusion, and late gadolinium enhancement (LGE). Results Thirty percent of the patients had abnormal rest perfusion, all of them corresponding to areas of mid-myocardial LGE and to a higher degree of segmental hypertrophy. Rest perfusion abnormalities correlated with more extensive and confluent LGE. The subgroup of patients with myocardial fibrosis and rest perfusion abnormalities (fibrosis+/perfusion+) had more than twice the incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring in comparison to patients with myocardial fibrosis and normal rest perfusion (fibrosis+/perfusion–) and patients with no fibrosis and normal rest perfusion (fibrosis–/perfusion–). Conclusions First-pass perfusion CMR identifies abnormal rest perfusion in a significant proportion of patients with HCM. These abnormalities are associated with the presence and distribution of myocardial scar and the degree of hypertrophy. Rest perfusion abnormalities identify patients with increased incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring, independently from the presence of myocardial fibrosis.

Late gadolinium enhancement on cardiac magnetic resonance and phenotypic expression in hypertrophic cardiomyopathy

BACKGROUNDnCardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) can identify areas of myocardial fibrosis in vivo in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the association between clinical-morphological variables, risk factor for sudden death, and LGE findings in a consecutive, unselected population of HCM patients.nnnMETHODSnFrom January 2005 to August 2009, 124 HCM patients (53 ± 17 years, 86 men) were prospectively evaluated with CMR examination, assessing left ventricular (LV) hypertrophy, function, and LGE.nnnRESULTSnIn univariate analysis, patients were divided into tertiles according to the number of segments positive for LGE (first tertile, 0.3 ± 0.4; second tertile, 2.2 ± 0.4; third tertile, 5.2 ± 1.9 segments). Male gender (P = .05), maximum LV wall thickness (P = .002), nonsustained ventricular tachycardia (P = .001), ejection fraction <50% (P = .02), LV mass (P = .02), left atrium dilation (P = .04), perfusion defects (P ≤ .001), and telesystolic volume (P = .04) were all positively related with the number of segments of LGE. In multivariable analysis, male gender (P = .007), maximum LV wall thickness (P = .006), LV mass (P = .031), and perfusion alterations (P = .017) were independent predictors of LGE extent.nnnCONCLUSIONSnOur study shows an independent association, even at multivariate analysis, between the entity of LGE and maximum LV wall thickness, mass, and perfusion defects in patients with HCM. Whether the presence and the extent of LGE translates into clinical events later on awaits further long-term follow-up studies.