Fernando R. Gutierrez

A Pattern-based Approach to Assessment of Delayed Enhancement in Nonischemic Cardiomyopathy at MR Imaging

Although delayed contrast material-enhanced cardiac magnetic resonance (MR) imaging has traditionally been used to evaluate ischemic disease and myocardial viability, it is increasingly being used in the evaluation of nonischemic cardiomyopathies. Unlike myocardial infarction, which demonstrates subendocardial or transmural delayed contrast enhancement in a vascular distribution, nonischemic cardiomyopathies demonstrate enhancement that is not limited to a vascular territory. In combination with other cardiac MR imaging features, the location (subendocardial, transmural, subepicardial, or mesocardial) and pattern (patchy or diffuse) of abnormal delayed myocardial enhancement allow differentiation between ischemic (infarct-related) and nonischemic cardiomyopathies and, in cases of nonischemic cardiomyopathy, narrowing of the differential diagnosis. With use of a structured approach, delayed contrast-enhanced cardiac MR imaging can be helpful in the early detection and appropriate treatment of nonischemic cardiomyopathies.

Transesophageal echocardiographic and clinical features of aortic intramural hematoma

OBJECTIVE This study sought to determine the transesophageal echocardiographic features and natural history of patients with aortic intramural hematoma. METHODS The transesophageal echocardiograms of all patients who had symptoms indicative of aortic dissection over 6 years were reviewed. Measurements were made of the involved aortic segment in the study patients, and follow-up was obtained. RESULTS In patients with aortic intramural hematoma, the wall thickness of the involved segment was significantly greater for descending segments than ascending segments (ascending aorta 7 +/- 2 mm, descending aorta 15 +/- 6 mm, p = 0.0016). In each case, the crescent-shaped intramural hematoma involved one wall predominantly, leading to compression of the aortic lumen. The findings of echolucent areas and displaced intimal calcium were found in the majority of patients. Four of eight patients with intramural hematoma of the ascending aorta were treated medically and four were treated surgically. The 30-day mortality was 50% in the medically treated patients and 0% in the surgically treated group. Four of 11 patients with isolated intramural hematoma of the descending aorta were treated medically and seven were treated surgically. All medically treated and 86% of surgically treated patients were alive at 30 days. CONCLUSIONS Aortic intramural hematoma has distinct and identifiable transesophageal echocardiographic features. These data support those of previous studies documenting high morbidity and mortality in patients with aortic intramural hematoma.

Increased stiffness and persistent narrowing of the aorta after successful repair of coarctation of the aorta: relationship to left ventricular mass and blood pressure at rest and with exercise.

Fifteen children and adolescents who had repair of coarctation of the aorta before age 15, who were not hypertensive at rest, and who had resting arm-leg blood pressure gradients of less than 20 mm Hg underwent noninvasive evaluation of left ventricular structure and function, aortic stiffness, and residual coarctation as well as bicycle exercise testing. These results were compared with those in 15 age- and sex-matched control subjects. The mean resting age-related systolic blood pressure percentiles (63% versus 46%), transverse aortic stiffness measured by the elastic modulus (Ep) (42.1 versus 23.2 kPa), stiffness index beta (beta) (3.66 versus 2.17), echocardiographic left ventricular fractional shortening (0.42 versus 0.36), left ventricular mass index (99.3 versus 81.0 gm/m2), maximum exercise right arm systolic blood pressure (173 versus 156 mm Hg), and exercise arm-leg blood pressure gradient (35 versus 6 mm Hg) were significantly increased in the coarctectomy patients compared with controls. Univariate correlations in the coarctectomy group showed significant relationships of residual aortic narrowing with left ventricular mass index (r = 0.68, p less than 0.01) and resting systolic blood pressure percentile for age (r = 0.55, p less than 0.05). Residual aortic narrowing did not significantly correlate with aortic stiffness, resting blood pressure gradient, or exercise blood pressure gradient. Neither left ventricular mass index nor resting systolic blood pressure percentile significantly correlated with age of repair or years after repair. These results demonstrate persistent abnormalities in aortic stiffness and left ventricular mass and function after successful repair of coarctation of the aorta in childhood and adolescence.(ABSTRACT TRUNCATED AT 250 WORDS)

MDCT of partial anomalous pulmonary venous return (PAPVR) in adults.

Purpose The purpose of this study was to determine the lobar distribution and associated radiologic/clinical findings of partial anomalous pulmonary venous return (PAPVR) in the adult population using multidetector computed tomography (MDCT). Materials and Methods The radiology information database was queried for patients with PAPVR diagnosed on chest computed tomography. Forty-seven cases of PAPVR were retrospectively identified from 45,538 contrast-enhanced chest computed tomography examinations performed over an 8-year period. Diagnostic findings were confirmed via consensus review by 2 cardiothoracic radiologists. Medical charts were evaluated for ancillary radiographic data, cardiopulmonary signs and symptoms, and subsequent surgical interventions. Results Calculated disease prevalence was 0.1%, with mean patient age of 58 years and a 58% female predominance. PAPVR was observed with 47% frequency in the left upper lobe, 38% right upper lobe (RUL), 13% right lower lobe, and 2% left lower lobe. Among cases of RUL PAPVR, 42% were associated with sinus venosus atrial septal defect (ASD). Other reported anomalies were right-sided volume overload (47%), isolated upper lobe PAPVR (29% left and 5% right), bilateral PAPVR (4%), scimitar syndrome (13%), persistent left superior vena cava (9%), and azygos continuation of the inferior vena cava (4%). Reported cardiopulmonary signs/symptoms and imaging modalities other than MDCT were neither sensitive nor specific for PAPVR. Surgical repair was performed in 21% of cases and included ASD patching, intracardiac baffle, anomalous vein anastomosis, systemic vein translocation, and Warden procedure. Conclusions This represents the largest and only consecutive retrospective study of PAPVR in adults to date. Left upper lobe PAPVR was the most frequent location detected on MDCT, whereas RUL PAPVR was slightly less common and moderately associated with sinus venosus ASD. Utilization of contrast-enhanced studies and MDCT technology has enabled improved detection and characterization of PAPVR for early diagnosis and/or intervention.

Spontaneous closure of secundum atrial septal defect in infants and young children

The records of 264 pediatric patients with uncomplicated ostium secundum atrial septal defect (ASD) were reviewed. Eighty-seven patients were younger than age 4 years at the time of cardiac catheterization. Subnormal weight gain, frequent pneumonia, cyanosis or tachypnea were present in 26 patients (30%). Of the 36 infants at catheterization, 17 (48%) had the previously described symptoms, including 12 (33%) who had congestive heart failure. Eight of the 36 infants were found to have closed their defect at a subsequent catheterization. Six of 18 patients who underwent cardiac catheterization between 1 and 2 years of age also had spontaneously closed their ASD at subsequent study. Statistical analysis of hemodynamic data revealed no difference (except a smaller shunt size) between ASDs that closed and those that did not in patients who were less than 4 years at initial catheterization. Analysis of hemodynamic data revealed no statistical differences between groups of patients with an ASD who were younger than and those older than 4 years at time of diagnostic study. Patients with ASDs that closed were significantly different from patients with atrial level shunting thought to be secondary to a valve-incompetent foramen ovale with respect to age at initial study (11 versus 2 months, p less than 0.001), mean left atrial pressure (7.7 versus 12.3 mm Hg, p less than 0.02) and difference between mean right and left atrial pressures (1.0 versus 4.2 mm Hg, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of pulmonary arterial morphology in cyanotic congenital heart disease by magnetic resonance imaging

Before and after surgical therapy, the anatomy of the pulmonary arteries in cyanotic congenital heart disease is often distorted. Pulmonary arterial anatomy was evaluated by magnetic resonance imaging (MRI) and angiography in 20 patients, ages 3 months to 20 years, with cyanotic heart disease associated with decreased pulmonary blood flow. Excellent correlation between MRI and angiographic estimates of pulmonary artery diameter was obtained (main pulmonary artery, r = 0.96; right pulmonary artery, r = 0.93; left pulmonary artery, r = 0.96). A similar excellent correlation (kappa = 0.83) was found in the assessment of the presence and severity of proximal pulmonary arterial stenoses. However, stenoses in the peripheral pulmonary arteries visualized with angiography were missed with MRI. MRI and angiography showed complete agreement in determining the patency of 11 surgical shunts. MRI did not demonstrate all of the systemic collateral vessels present with angiography, and the distal connections of collaterals were not detected with MRI. MRI is comparable to angiography in the evaluation of central pulmonary arterial anatomy over a wide range of ages. These findings suggest an important role for noninvasive MRI in the serial evaluation of pulmonary artery morphology in patients with cyanotic congenital heart disease before and after surgical repair.

Imaging Patients with Cardiac Trauma

In the United States, trauma is the leading cause of death among those who are 1-44 years old, with cardiovascular injuries representing the second most common cause of traumatic death after central nervous system injuries. Evaluation of trauma patients with suspected cardiac injury may be complex and include electrocardiography, measurement of cardiac biomarkers, and imaging examinations. Contrast material-enhanced computed tomography (CT) has become one of the most valuable imaging tools available for evaluating hemodynamically stable patients with suspected cardiac injury. The presence of hemopericardium, with or without cardiac tamponade, is one of the most significant findings of cardiac injury. Other complications that result from blunt cardiac injury, such as pericardial rupture and cardiac herniation, may be readily depicted at multidetector CT. Assessment of patients with cardiac injuries, particularly those with penetrating injuries, is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis. Patients who are hemodynamically stable, particularly those with penetrating cardiac injuries, also may benefit from a timely imaging examination. In addition to chest radiography, other available modalities such as transthoracic and transesophageal echocardiography, nuclear medicine, and magnetic resonance imaging may play a role in selected cases.

Chest Radiography in Thoracic Polytrauma

OBJECTIVE Chest radiography is the first-line imaging examination for assessment of thoracic polytrauma, serving to evaluate the extent of injury and facilitate early triage to observation, further imaging, or immediate surgical intervention. The objective of this article is to review the spectrum of injuries that occur in the chest and upper abdomen after blunt and penetrating trauma. Pathophysiology, imaging findings, and management recommendations will be discussed for injuries to the chest wall, diaphragm, pleura, lungs, mediastinum, heart, aorta, and great vessels. CONCLUSION Chest radiography plays an important role in the initial evaluation of blunt and penetrating chest trauma, providing rapid imaging information to supplement the history and physical examination. In the emergency department, familiarity with the spectrum of injuries that can occur in the chest and upper abdomen is important for accurate interpretation of chest radiographs as well as establishment of appropriate recommendations for management and follow-up.

Congenital Thoracic Vascular Anomalies

Congenital vascular anomalies of the thorax represent an important group of entities that can occur either in isolation or in association with different forms of congenital heart disease. It is extremely important that radiologists have a clear understanding of these entities, their imaging characteristics, and their clinical relevance. The imaging armamentarium available to diagnose these diverse conditions is ample, and has evolved from such traditional methods as chest radiography, barium esophagography, and angiography to new modalities that include echocardiography, multidetector row CT (MDCT), and MR imaging. These imaging modalities have added safety, speed, and superb resolution in diagnosis and, as in the case of MDCT, provide additional information about the airway and lung parenchyma, resulting in a more comprehensive examination with greater anatomic coverage. This article reviews the most important congenital thoracic vascular anomalies, their embryologic foundation, clinical presentation, and imaging characteristics, especially those of MDCT.

Primary leiomyosarcoma of the pulmonary artery: A diagnostic dilemma

Primary leiomyosarcoma of the pulmonary artery is a rare malignancy arising from the multipotential mesenchymal cell of the intima of the pulmonary artery. Due to its rarity and nonspecific clinical symptoms, the correct diagnosis and proper management are often delayed. Furthermore, it is frequently misdiagnosed as pulmonary embolism, mediastinal mass, pulmonary stenosis and lung cancer. Therefore, it is important to consider primary leiomyosarcoma of the pulmonary artery a possibility when a persistent filling defect is present in the pulmonary artery and there is no response to optimal anticoagulation treatment. Radiologic findings such as a unilateral mass continuously filling the pulmonary artery, inhomogenous enhancement, vascular distension, extravascular invasion into adjacent structure or uptake in the area of tumor on the FDG-PET can be helpful when differentiating pulmonary artery sarcoma (PAS) from chronic thromboembolism.