Giampaolo Gavelli

Evolution of aortic dissection after surgical repair

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.

Contribution of magnetic resonance imaging in the differential diagnosis of cardiac amyloidosis and symmetric hypertrophic cardiomyopathy

BACKGROUND Magnetic resonance imaging (MRI) provides a high-resolution study of atrial and ventricular myocardium depicting morphologic alterations in cardiomyopathies. Furthermore, in systemic amyloidosis, MRI demonstrates the capability to detect amyloid protein by tissue characterization. The aim of this study was to evaluate the potential of MRI in the diagnosis of cardiac amyloidosis. METHODS MRI was performed in 16 patients with cardiac amyloidosis and in 10 patients with symmetric hypertrophic cardiomyopathy. Myocardial ventricular and atrial thickness (septum, posterior, and lateral wall), right and left ventricular diastolic diameter, and atrial surface were compared. Ventricular myocardium signal intensity was then evaluated by sequences with an echo time (TE) of 20 and 60 ms as the expression of myocardial texture modification. RESULTS Significant morphologic differences between cardiac amyloidosis and hypertrophic cardiomyopathy were found in the right atrium surface (21.9 vs 17.2 cm2, respectively; P = .05), myocardial thickness of right atrial wall (9.3 vs 4.9 mm; P < .0001 ), and right ventricular free wall (10.6 vs 8.9 mm; P = .011 ). No significant differences were found in the interventricular septum (16.6 vs 17.8 mm), left ventricular posterior wall (18.2 vs 18.8 mm), and left atrial surface (17.4 vs 17.2 cm2). The signal intensity of cardiac amyloidosis was significantly lower with both TE 20 and TE 60 in comparison with hypertrophic cardiomyopathy and to a group of healthy volunteers. CONCLUSIONS MRI has a potential role in the noninvasive diagnosis of cardiac amyloidosis identifying typical morphologic markers and suggesting the presence of infiltrative disease by tissue characterization.

The impact of lung cancer on survival of idiopathic pulmonary fibrosis.

BACKGROUND Lung cancer (LC) is frequently associated with idiopathic pulmonary fibrosis (IPF). Despite this well-known association, the outcome of LC in patients with IPF is unclear. The objective of this study was to evaluate the impact of LC on survival of patients with associated IPF. METHODS A total of 260 patients with IPF were reviewed, and 186 IPF cases had complete clinical and follow-up data. Among these, five cases were excluded because LC was radiologically suspected but not histologically proven. The remaining 181 cases were categorized in two groups: 23 patients with biopsy-proven LC and IPF (LC-IPF) and 158 patients with IPF only (IPF). Survival and clinical characteristics of the two groups were compared. RESULTS Prevalence of histologically proven LC was 13%, and among those with LC-IPF cumulative incidence at 1 and 3 years was 41% and 82%. Patients with LC were more frequently smokers (91.3% vs 71.6%, P = .001), with combined pulmonary fibrosis and emphysema (52% vs 32%, P = .052). Survival in patients with LC-IPF was significantly worse than in patients with IPF without LC (median survival, 38.7 months vs 63.9 months; hazard ratio = 5.0; 95% CI, 2.91-8.57; P < .001). Causes of death in the study group were respiratory failure in 43% of patients, LC progression in 13%, and LC treatment-related complications in 17%. CONCLUSIONS In patients with IPF, LC has a significant adverse impact on survival. Diagnosis and treatment of LC in IPF are burdened by an increased incidence of severe complicating events, apparently as lethal as the cancer itself.

Delayed treatment of isthmic aortic rupture

Traumatic rupture of the thoracic aorta is a life-threatening injury with a high mortality, and is difficult to manage in polytraumatized patients. Between 1980 and 1998, 50 patients were admitted to our Department with acute traumatic aortic rupture (TAR). The site of lesion was usually isthmic (86% of patients). From 1980 to 1992, 21 patients (Group I) underwent emergency surgical repair; from 1992 to January 1998, 29 patients (Group II) underwent intensive medical treatment, except one who was haemodynamically unstable and died 8h after the trauma from a massive haemothorax before an emergency thoracotomy could be attempted. The aortic rupture was followed up by MRI or CT scan. Twenty-one patients in Group II underwent aortic repair an average of 8.6 months after the injury. In two patients the operation was expedited because of an enlarging aortic aneurysm. In Group I the postoperative mortality was 19%, three patients developed postoperative paraplegia and one acute renal failure. In Group II there were no postoperative deaths and no major complications.

Pulmonary complications of liver transplantation: radiological appearance and statistical evaluation of risk factors in 300 cases.

Abstract. The aim of this study was to evaluate the incidence, radiographic appearance, time of onset, outcome and risk factors of non-infectious and infectious pulmonary complications following liver transplantation. Chest X-ray features of 300 consecutive patients who had undergone 333 liver transplants over an 11-year period were analysed: the type of pulmonary complication, the infecting pathogens and the mean time of their occurrence are described. The main risk factors for lung infections were quantified through univariate and multivariate statistical analysis. Non-infectious pulmonary abnormalities (atelectasis and/or pleural effusion: 86.7 %) and pulmonary oedema (44.7 %) appeared during the first postoperative week. Infectious pneumonia was observed in 13.7 %, with a mortality of 36.6 %. Bacterial and viral pneumonia made up the bulk of infections (63.4 and 29.3 %, respectively) followed by fungal infiltrates (24.4 %). A fairly good correlation between radiological chest X-ray pattern, time of onset and the cultured microorganisms has been observed in all cases. In multivariate analysis, persistent non-infectious abnormalities and pulmonary oedema were identified as the major independent predictors of posttransplant pneumonia, followed by prolonged assisted mechanical ventilation and traditional caval anastomosis. A “pneumonia-risk score” was calculated: low-risk score ( < 2.25) predicts 2.7 % of probability of the onset of infections compared with 28.7 % of high-risk ( > 3.30) population. The “pneumonia-risk score” identifies a specific group of patients in whom closer radiographic monitoring is recommended. In addition, a highly significant correlation (p < 0.001) was observed between pneumonia-risk score and the expected survival, thus confirming pulmonary infections as a major cause of death in OLT recipients.

High resolution CT and histological findings in idiopathic pleuroparenchymal fibroelastosis: Features and differential diagnosis

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a recently described clinical-pathologic entity characterized by pleural and subpleural parenchymal fibrosis, mainly in the upper lobes. As this disease is extremely rare (only 7 cases have been described in the literature to date) poorly defined cases of IPPFE can go unrecognized.The clinical course of disease is progressive and prognosis is poor, with no therapeutic options other than lung transplantation currently available, yet. The aim of this report is to describe two further cases of this rare disease, reviewing CT, clinical and histological features.

Delayed Surgery of Traumatic Aortic Rupture: Role of Magnetic Resonance Imaging

BACKGROUND Traumatic aortic rupture (TAR) is a pathological entity with a high mortality, both spontaneous and perioperative. Delayed surgical repair has been proposed when associated lesions are stabilized. The aim of this study was to validate MRI for detecting both the presence and type of TAR and to monitor posttraumatic aneurysm and associated lesions. METHODS AND RESULTS Twenty-four consecutive patients with acute chest trauma and suspected aortic rupture, as suggested by emergency CT or chest radiographs, were subjected to MRI and/or angiography in random order. Such parameters as the presence and type of lesion; presence of periaortic, pericardial, mediastinal, or pleural effusion; and presence of associated lesions were considered in every patient. Follow-up imaging was performed exclusively by MRI every 1 to 2 months. TAR was present in 20 patients. No patient underwent surgery in the acute phase; 14 patients underwent surgery at 6.8 +/- 2.7 months; 5 are waiting for surgery; and 1 healed spontaneously. There was no overall mortality. For detection of TAR, the accuracy of MRI was 100%; angiography, 84%; and CT, 69%. In detecting the type of lesion, the diagnostic accuracy of MRI was 92%. During follow-up, a significant increase in the posttraumatic aneurysm was observed in 2 patients, and surgical repair was initiated. CONCLUSIONS In chest trauma patients, MRI provides complete anatomic data to assess the severity of aortic and thoracic lesions. Moreover, along with the concept of delayed surgical repair of TAR, MRI is the ideal modality to monitor and follow TAR before surgical repair.

Extension of dissection in stent-graft treatment of type B aortic dissection: lessons learned from endovascular experience.

Endovascular treatment is becoming the most important treatment modality in the complex management of type B dissection, providing benefits to both acute and chronic patients. Growing technical experience and improving stent-graft devices have resulted in better patient outcome and expanded clinical indications. Nevertheless, similar to any treatment option, this less invasive method has its inherent risks. Several cases of iatrogenic dissection have been reported in the literature, underlying the need for guidelines to minimize this risk and improve procedural safety. Extension of the dissection after endovascular repair of type B dissection does not appear to be device-specific, but related primarily to aortic wall alterations or adverse anatomy that arise most frequently in hypertensive patients or those with challenging aortic configuration. An accurate examination of the aortic wall and dissection anatomy and careful intraprocedural device manipulation and balloon molding may help avoid this potentially life-threatening complication.

Prevalence of thoracolumbar vertebral fractures on multidetector CT: Underreporting by radiologists

OBJECTIVE To evaluate the prevalence of osteoporotic vertebral fractures in patients undergoing multidetector computed tomography (MDCT) of the chest and/or abdomen. MATERIALS AND METHODS 323 consecutive patients (196 males, 127 females) with a mean age of 62.6 years (range 20-88) who had undergone chest and/or abdominal MDCT were evaluated. Sagittal reformats of the spine obtained from thin section datasets were reviewed by two radiologists and assessed for vertebral fractures. Morphometric analysis using electronic calipers was performed on vertebral bodies which appeared abnormal upon visual inspection. A vertebral body height loss of 15% or more was considered a fracture and graded as mild (15-24%), moderate (25-49%) or severe (more than 50%). Official radiology reports were reviewed and whether the vertebral fractures had been reported or not was noted. RESULTS 31 out of 323 patients (9.5%) had at least 1 vertebral fracture and 7 of those patients had multiple fractures for a total of 41 fractures. Morphometric grading revealed 10 mild, 16 moderate and 15 severe fractures. Prevalence was higher in women (14.1%) than men (6.6%) and increased with patients age with a 17.1% prevalence in post-menopausal women. Only 6 out 41 vertebral fractures (14.6%) had been noted in the radiology final report while the remaining 35 (85.45) had not. CONCLUSION although vertebral fractures represent frequent incidental findings on multidetector CT studies and may be easily identified on sagittal reformats, they are often underreported by radiologists, most likely because of unawareness of their clinical importance.

Assessment of restrictive cardiomyopathy of amyloid or idiopathic etiology by magnetic resonance imaging.

This study was designed to assess the role of magnetic resonance imaging in the differential diagnosis of amyloid and idiopathic etiology of cardiomyopathy. This technique demonstrated the capability to differentiate the 2 forms, providing high-resolution evaluation of the myocardial wall and detecting the infiltrative pathology by tissue characterization.