Lorenzo Pagnan

Magnetic resonance imaging in right ventricular dysplasia

Fifteen patients with right ventricular dysplasia were investigated by T1-weighted spin- and gradient-echo pulse sequences, using a protocol that enabled both a subjective analysis of myocardial signal intensity and a quantitative/qualitative analysis of right and left ventricular function. In 8 patients, 3 investigators independently recognized abnormally hyperintense areas in the anatomic sites usually affected by the disease. In 7 of these patients, these areas showed an overlap with a-dyskinetic areas imaged by both magnetic resonance imaging (MRI) and echocardiography. In 1 patient who underwent a cardiac transplant, MRI of the explanted heart showed an excellent correlation between the distribution of the lesions and the in vivo/in vitro features. The data were compared with those from an equivalent sample of patients affected by dilated cardiomyopathy. In the latter patients, no focal hyperintensities were attributed to any anatomic sites in the right ventricule, and no focal a-dyskinetic foci were observed. Furthermore, the 2 groups of patients were significantly different in regard to dimensional and functional quantitative parameters. The results suggest that MRI is useful in integrating echocardiographic data and can be helpful in diagnosing this disease in late stages.

Ultrasonography and Plain Film Versus Intravenous urography in ureteric colic

Urography (IVU) is considered the best first investigation in patients with suspected ureteric colic, but recently ultrasonography (US), combined with a plain film of the abdomen (KUB), has been suggested as an alternative. We have undertaken a prospective study to see if this approach can be used in an Emergency Department by radiologists with different amounts of ultrasound experience. Some 180 patients with suspected ureteric colic presenting to the Emergency Department over an 8-month period were studied. They had a plain abdominal film (KUB) and US examination of the kidneys, ureters and bladder following hydration. Some 120 patients subsequently underwent IVU at a mean interval of 3.5 days after the ultrasound examination. Of these, 15 patients passed a stone before their IVU. Of the remaining 105 patients, 44 had an IVU positive for stone and 61 had a negative IVU. Fifty of the 60 patients who did not have an IVU had clinical follow-up and 31 had ultrasound. Our findings in this prospective study suggest that in the hydrated patient the combination of KUB plus US is a sensitive but not very specific screening test (sensitivity 95%, specificity 67%). Because of the high negative predictive value of KUB plus US (95%), urography is not likely to be helpful when KUB plus US are negative. Urography is indicated only if KUB plus US findings are equivocal or if intervention is necessary. If we had used KUB plus US alone as the first test in our patients, urography would have been unnecessary in approximately 60%. Twenty per cent of our patients passed a stone in the first 48 h.

Utility of Cardiac Magnetic Resonance Imaging to Differentiate Cardiac Sarcoidosis from Arrhythmogenic Right Ventricular Cardiomyopathy

Some patients diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) are eventually found to have cardiac sarcoidosis (CS). Accurate differentiation between these 2 conditions has implications for immunosuppressive therapy and familial screening. We sought to determine whether cardiac magnetic resonance imaging (MRI) could be used to identify the characteristic findings to accurately differentiate between CS and ARVC. Consecutive patients with a diagnostic MRI scan indicating CS and/or ARVC constituted the cohort. All patients diagnosed with CS had histologic confirmation of sarcoidosis, and all patients with ARVC met the diagnostic task force criteria. The cardiac MRI data were retrospectively analyzed to identify possible differentiating characteristics. Of the patients, 40 had CS and 21 had ARVC. Those with CS were older and had more left ventricular scar. The presence of mediastinal lymphadenopathy or left ventricular septal involvement was seen exclusively in the patients with CS (p <0.001). A family history of sudden cardiac death was seen only in the ARVC group (p = 0.012). The right ventricular ejection fraction and ventricular volumes were also significantly different between the 2 groups. In conclusion, patients with CS have significantly different cardiac MRI characteristics than patients with ARVC. The cardiac volume, in addition to the degree and location of cardiac involvement, can be used to distinguish between these 2 disease entities. The presence of mediastinal lymphadenopathy and left ventricular septal scar favors a diagnosis of CS and not ARVC. Consideration of CS should be given if these MRI findings are observed during the evaluation for possible ARVC.

Right Ventricular Dysplasia With Biventricular Involvement

A23-year-old man was admitted to the hospital with severe heart failure and cachexia. Ventricular arrhythmias and progressive heart failure (predominantly right heart) had been observed in the previous 3 years. Physical examination was unremarkable except for a widely split second heart sound, a systolic left precordial lift, third and fourth heart sounds, and signs of increased venous pressure. Chest radiography showed significant cardiomegaly. The ECG was characterized by right atrial enlargement, low QRS voltages, wide complexes in the right precordial leads (epsilon waves?), and negative T waves. Nonsustained ventricular tachycardia with polymorphic configuration was observed at ambulatory ECG monitoring. The echocardiogram (Figure 1⇓) disclosed severe right ventricular enlargement, with aneurysm at the level of the outflow, severe depression …

Renal artery stenosis: comparative evaluation with gadolinium-enhanced MRA and DSA

Purpose This study was undertaken to evaluate the accuracy of contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting renal artery stenosis using intra-arterial digital subtraction angiography (DSA) as the gold standard.

Infiltrative/Storage Cardiomyopathies: Clinical Assessment and Imaging in Diagnosis and Patient Management

Infiltrative/storage cardiomyopathies (CMP) are diseases characterized by the deposition of pathological substances in the heart muscle. In particular, the term infiltrative refers to intercellular infiltration, whereas storage refers to intracellular deposition within the myocardium. As the infiltration/storage usually involves multiple organs, these CMP should be considered part of a systemic disorder. Despite variable etiology and pathological mechanisms, this group of CMP shares some common features, such as myocardial hypertrophy and progressive myocardial stiffness, with diastolic and systolic dysfunction. Heart failure is the main clinical manifestation, but arrhythmias and conduction defects are common. Accurate clinical evaluation is therefore crucial for correctly targeting further examinations. Moreover, cardiac imaging plays a major role not only in differential diagnosis but also in prognostic stratification. The impact of identifying cardiac involvement and the underlying pathology reflects upon treatment and prognosis.

Other Cardiomyopathies: Clinical Assessment and Imaging in Diagnosis and Patient Management

In this chapter describes clinical and imaging assessment in diagnosis and patient management of other cardiomyopathies (CMP) not included among the previously defined main groups of CMP. Most of these unclassified CMP are characterized by frequent reversibility of myocardial dysfunction after adequate treatment. The peculiar form called left ventricular noncompaction is also addressed.

Role of Basic and Advanced Imaging in Cardiomyopathies

Basic and advanced imaging plays a pivotal role in cardiomyopathies (CMP), not only for determining the diagnosis but also for assessing prognosis, guiding patient management, detecting disease progression, evaluating treatment, and screening asymptomatic relatives of individuals affected by familial forms of the disease. Echocardiography is an optimal, low-cost and highly reproducible noninvasive diagnostic tool that can often provide a comprehensive evaluation of the typical morphological and functional characteristics of CMP. Furthermore, it is the imaging approach of choice for CMP follow-up. Advanced noninvasive imaging techniques, such as cardiac magnetic resonance, computed tomography, and nuclear imaging can be useful in selected and more challenging cases and display an important role in risk stratification of patients with CMP.

Other Imaging Modalities in the Assessment of Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a diagnostic challenge for even the most experienced cardiologist. Cardiac magnetic resonance (CMR) has gained widespread acceptance as a main imaging technique in the assessment of this condition owing to its 3D, multiplanar capabilities, excellent spatial and temporal resolution, and optimal contrast between blood pool and myocardium. It offers the possibility of performing noninvasive tissue characterization of fatty infiltration and fibrosis and detailed assessment of ventricular regional and global systolic and diastolic function. The role of other imaging modalities, such as positron emission tomography (PET), single-photon-emission tomography (SPECT), computed tomography (CT), and right ventriculography (RV*), is also reviewed.