Hollins P. Clark

Prediction of Cardiac Events in Patients With Reduced Left Ventricular Ejection Fraction With Dobutamine Cardiovascular Magnetic Resonance Assessment of Wall Motion Score Index

OBJECTIVES The purpose of this study was to assess the utility of dobutamine cardiovascular magnetic resonance (DCMR) results for predicting cardiac events in individuals with reduced left ventricular ejection fraction (LVEF). BACKGROUND It is unknown whether DCMR results identify a poor cardiac prognosis when the resting LVEF is moderately to severely reduced. METHODS Two hundred consecutive patients ages 30 to 88 (average 64) years with an LVEF <or=55% that were poorly suited for stress echocardiography underwent DCMR in which left ventricular wall motion score index (WMSI), defined as the average wall motion of the number of segments scored, was assessed at rest, during low-dose, and after peak intravenous infusion of dobutamine/atropine. All participants were followed for an average of 5 years after DCMR to ascertain the post-testing occurrence of cardiac death, myocardial infarction (MI), and unstable angina or congestive heart failure warranting hospital stay. RESULTS After accounting for risk factors associated with coronary arteriosclerosis and MI, a stress-induced increase in WMSI during DCMR was associated with future cardiac events (p < 0.001). A DCMR stress-induced change in WMSI added significantly to predicting future cardiac events (p = 0.003), after accounting for resting LVEF, but this predictive value was confined primarily to those with an LVEF >40%. CONCLUSIONS In individuals with mild to moderate reductions in LVEF (40% to 55%), dobutamine-induced increases in WMSI forecast MI and cardiac death to a greater extent than an assessment of resting LVEF. In those with an LVEF <40%, a dobutamine-induced increase in WMSI does not predict MI and cardiac death beyond the assessment of resting LVEF.

Feasibility to detect severe coronary artery stenoses with upright treadmill exercise magnetic resonance imaging

We performed treadmill exercise magnetic resonance imaging in 27 patients with exertional chest pain who were referred for contrast coronary angiography to determine the feasibility of this method to identify severe coronary artery stenoses. The sensitivity and specificity for detecting >70% coronary artery luminal diameter narrowings on contrast coronary angiography were 79% and 85%, respectively.

Left ventricular infarct size assessed with 0.1 mmol/kg of gadobenate dimeglumine correlates with that assessed with 0.2 mmol/kg of gadopentetate dimeglumine.

Objective: To determine myocardial infarct (MI) size during cardiovascular magnetic resonance at 1.5 Tesla using 0.1 mmol/kg body weight of gadobenate dimeglumine (Gd-BOPTA) and 0.2 mmol/kg body weight of gadopentetate dimeglumine (Gd-DTPA). Methods: Twenty participants (16 men, 4 women), aged 58 ± 12 years, with a prior chronic MI were imaged in a crossover design. Participants received 0.2 mmol/kg body weight of Gd-DTPA and 0.1 mmol/kg body weight of Gd-BOPTA on 2 occasions separated by 3 to 7 days. Results: The correlations were high between Gd-DTPA and Gd-BOPTA measures of infarct volume (r = 0.93) and the percentage of infarct relative to left ventricular myocardial volume (r = 0.85). The size and location of the infarcts were similar (P = 0.9) for the 2 contrast agents. Interobserver correlation of infarct volume (r = 0.91) was high. Conclusions: In chronic MI, late gadolinium enhancement identified with a single 0.1 mmol/kg body weight dose of Gd-BOPTA is associated in volume and location to a double (0.2 mmol/kg body weight) dose of Gd-DTPA. Lower doses of higher relaxivity contrast agents should be considered for determining left ventricular myocardial infarct size.

The Radiologist as a Palliative Care Subspecialist: Providing Symptom Relief When Cure Is Not Possible

OBJECTIVE The purpose of this study was to determine the percentage of patients referred to an interventional radiology (IR) practice who need palliative care and to examine the training required for a diplomate of the American Board of Radiology (ABR) to qualify for the hospice and palliative medicine certifying examination. MATERIALS AND METHODS This retrospective study reviewed all patient referrals to an academic vascular and IR practice during the month of August 2009. The demographics, underlying diagnosis, and the type of procedures performed were ascertained from the electronic medical record. The requirements for a diplomate of the ABR to obtain certification as a hospice and palliative medicine subspecialist were evaluated and summarized. RESULTS Two-hundred eighty-two patients were referred to the IR service and underwent a total of 332 interventional procedures. Most of the patients (229 [81.2%]) had underlying diagnoses that would warrant consultation with a hospice and palliative medicine subspecialist; these patients were significantly older (58.5 vs 44.7 years; p < 0.01) and underwent more procedures (1.21 vs 1.02; p < 0.01). To obtain a subspecialty certification in hospice and palliative medicine, a radiologist needs certification by the ABR, an unrestricted medical license, 2 years of subspecialty training in hospice and palliative medicine, 100 hours of interdisciplinary hospice and palliative medicine team participation, active care of 50 terminally ill adult patients, and successful performance on the certification examination. CONCLUSION Procedures related to palliative care currently compose the majority of our IR cases. Certification in hospice and palliative medicine can be achieved with a modest investment of time and clinical training.

Computed tomography pulmonary findings in healthy older adult aspirators versus nonaspirators

In previous studies, we consistently found that approximately 30% of asymptomatic healthy older adults silently aspirated liquids during a flexible endoscopic evaluation of swallowing (FEES) and that their aspiration status was stable for the following year. However, no studies have systematically evaluated effects of silent aspiration on lung parenchyma and airways. We used computed tomography (CT) to compare lungs of healthy older adult aspirators versus nonaspirators. We hypothesized that CT images would show pulmonary differences in healthy older adult aspirators versus nonaspirators.

Computed tomography fluoroscopy versus conventional computed tomography guidance for biopsy of intrathoracic lesions: a retrospective review of 1143 consecutive procedures.

Purpose: To compare the success rates, complication rates, and radiation doses of conventional computed tomography (CCT) versus computed tomography with fluoroscopy (CTF) during image-guided percutaneous needle biopsies of intrathoracic lesions. Materials and Methods: We conducted a retrospective analysis of 1143 consecutive intrathoracic biopsies performed under computed tomography guidance at a single tertiary care center. For each procedure we recorded patient age and sex, lesion size and location, and radiation dose administered to the patient. Thereafter, appropriate tests of statistical significance were applied to compare rates of success, complications, and radiation between CCT and CTF guidance. Results: After correcting for lesion size, CTF was associated with an odds ratio (OR) of 6.07 [95% confidence interval (CI): 2.23-16.50] for technical procedural success, an OR of 0.79 (95% CI: 0.55-1.15) for fine-needle aspiration success, an OR of 2.11 (95% CI: 1.02-4.38) for core-needle biopsy success, and an OR of 1.45 (95% CI: 1.00-2.21) for overall success when compared with CCT. CTF was associated with an OR of 1.10 (95% CI: 0.35-3.48) for complications when compared with CCT. Mean dose-length product per procedure was 1332 mGy cm for CCT and 1730 mGy cm for CTF (P=0.027). Conclusions: CCT and CTF are both valuable tools for intrathoracic biopsy. CTF improves technical and core-needle biopsy success at the expense of higher radiation doses to the patient. Operator confidence with CCT and CTF in light of lesion characteristics should guide the choice to select one over the other.

Successful Radiofrequency Ablation for Recurrent Pulmonary Hepatoblastoma

To the Editor: The optimal treatment of lung metastases in patients with hepatoblastoma is unclear. Minimally invasive surgical techniques are generally safe and effective, but morbidity can be significant and limited prospective data exist.[1] Radiofrequency ablation (RFA) is one of the several minimally invasive thermal-based technologies which have been safely and successfully used to treat primary andmetastatic solid tumors.[2]We report here the first successful treatment of pulmonary metastasis in a patient with recurrent hepatoblastoma using RFA. A 2-year-old Caucasian male was diagnosed with a large, unresectable hepatoblastoma. Serum AFP was 1,885,000 ng/ml (normal range 0–10 ng/ml). Computed tomography (CT) of the chest showed no metastases. He was treated with four cycles of cisplatin, vincristine, and 5-fluorourocil. The tumor decreased in size and AFP decreased to 209,100 ng/ml. However, the tumor remained unresectable, and the patient underwent an unrelated cadaveric liver transplant. No post-transplant chemotherapy was administered due to a perceived high risk to benefit ratio. His posttransplant AFP nadir was 22.1 ng/ml 2months after transplant, but it rose in the following 6 weeks to 151.7 ng/ml, when CT revealed three pulmonary nodules, all 5mm (one in the right upper lobe and two in the left upper lobe). He was treated with two cycles of doxorubicin and ifosfamide, but the AFP continued to rise. He was then treated with irinotecan, which resulted in the AFP decreasing from 286 to 48 ng/ml, but no change in the size of the pulmonary nodules. He then underwent thoracotomy with right upper lobe wedge resection. His post-operative course was complicated by air leak, atelectasis, and pleural effusions. After surgery, his parents elected against left-sided thoracotomy, and irinotecan was resumed. His AFP level fell to 31.9 ng/ml, but increased over the next 6 months to 91.8 ng/ml. Follow-up CT revealed a single 7mm pulmonary nodule in the left upper lobe with no other sites of disease. To avoid another surgery, the patient underwent CT-guided RFA under general anesthesia. The procedure was successful and without complication, and the patient was discharged home the next day. Following RFA theAFP normalized, the nodule disappeared on imaging, and he has been disease free for 37 months. One pediatric patient with hepatoblastoma and one with liver metastasis from a Wilms tumor have been successfully treated with liver-directed RFA,[3] as has a 2 year old with locally recurrent hepatoblastoma.[4] RFAwas unsuccessful in one reported patient with pulmonary hepatoblastoma.[5] A pilot study of RFA in children with recurrent solid tumors demonstrated limited toxicity and possible benefit in selected patients.[6] In our case, the toxicity of RFA was almost nil, and the result has been prolonged disease-free survival. This report shows that RFA can be a successful treatment modality for pulmonary metastatic lesions from hepatoblastoma. Given its potential efficacy combined with a side-effect profile comparable to or perhaps better than current surgical modalities, RFA offers an alternative to surgery in the treatment of pulmonary metastatic hepatoblastoma.

Detection of Pseudoaneurysm of the Left Ventricle by Fast Imaging Employing Steady-State Acquisition (FIESTA) Magnetic Resonance Imaging

This report highlights the importance of interpretating images throughout the course of a dobutamine MRI stress test. Upon review of the baseline images, the left ventricular (LV) endocardium was not well seen due to flow artifacts associated with low intracavitary blood-flow velocity resulting from a prior myocardial infarction. Physicians implemented a cine fast imaging employing steady-state acquisition (FIESTA) technique that was not subject to low flow artifact within the LV cavity. With heightened image clarity, physicians unexpectedly identified a LV pseudoaneurysm.

CT Pulmonary Findings in Healthy Older Adult Aspirators versus Nonaspirators

In previous studies, we consistently found that approximately 30% of asymptomatic healthy older adults silently aspirated liquids during a flexible endoscopic evaluation of swallowing (FEES) and that their aspiration status was stable for the following year. However, no studies have systematically evaluated effects of silent aspiration on lung parenchyma and airways. We used computed tomography (CT) to compare lungs of healthy older adult aspirators versus nonaspirators. We hypothesized that CT images would show pulmonary differences in healthy older adult aspirators versus nonaspirators.

Computed tomography pulmonary findings in healthy older adult aspirators versus nonaspirators: Pulmonary CT in Aspirators vs. Nonaspirators

In previous studies, we consistently found that approximately 30% of asymptomatic healthy older adults silently aspirated liquids during a flexible endoscopic evaluation of swallowing (FEES) and that their aspiration status was stable for the following year. However, no studies have systematically evaluated effects of silent aspiration on lung parenchyma and airways. We used computed tomography (CT) to compare lungs of healthy older adult aspirators versus nonaspirators. We hypothesized that CT images would show pulmonary differences in healthy older adult aspirators versus nonaspirators.