Luigi Natale

Relation between stress-induced myocardial perfusion defects on cardiovascular magnetic resonance and coronary microvascular dysfunction in patients with cardiac syndrome X.

OBJECTIVES The purpose of this study was to investigate whether a direct relation can be demonstrated between myocardial perfusion defects detected during dobutamine stress test (DST) by cardiovascular magnetic resonance (CMR) and impairment of coronary microvascular dilatory function in patients with cardiac syndrome X (CSX). BACKGROUND Despite the fact that coronary microvascular dysfunction has been shown in most patients with CSX, the ischemic origin of CSX remains debated. No previous study assessed whether a strict relation exists between abnormalities in myocardial perfusion and coronary microvascular dysfunction in CSX patients. METHODS Eighteen CSX patients (mean age 58 +/- 7 years, 7 men) and 10 healthy control subjects (mean age 54 +/- 8 years, 4 men) underwent myocardial perfusion study by gadolinium-enhanced CMR at rest and at peak DST (maximal dose 40 microg/kg/min). Coronary flow response (CFR) to adenosine (140 microg/kg/min in 90 s) in the left anterior descending (LAD) coronary artery was assessed by high-resolution transthoracic echo-Doppler and expressed as the ratio between coronary flow velocity at peak adenosine and at rest. RESULTS At peak DST, reversible perfusion defects on CMR were found in 10 CSX patients (56%) but in none of the control subjects (p = 0.004). The CFR to adenosine in the LAD coronary artery was lower in CSX patients than in control subjects (2.03 +/- 0.63 vs. 3.29 +/- 1.0, p = 0.0004). The CSX patients with DST-induced myocardial perfusion defects in the LAD territory on CMR had a lower CFR to adenosine compared with those without perfusion defects in the LAD territory (1.69 +/- 0.5 vs. 2.31 +/- 0.6, p = 0.01). A significant correlation was found in CSX patients between CFR to adenosine and a DST perfusion defect score on CMR in the LAD territory (r = -0.45, p = 0.019). CONCLUSIONS Our data concurrently show DST-induced myocardial perfusion defects on CMR and reduced CFR in the LAD coronary artery territory in CSX patients, thus giving strong evidence that a dysfunction of coronary microcirculation resulting in myocardial perfusion abnormalities is present in these patients.

Diagnostic imaging of primitive neuroectodermal tumour of the chest wall (Askin tumour)

Objectives. To describe the radiological features of primitive neuroectodermal tumour (PNET) of the chest wall (Askin tumour) at diagnosis and to analyse the radiological changes occurring as a consequence of treatment and during follow-up. Materials and methods. Nine children with histologically proven PNET were studied. At diagnosis, all patients underwent chest X-ray (CXR), chest CT and bone scintigraphy; three patients also had MR and three had US. During treatment and follow-up, CT was performed in all patients. Results. CT demonstrated a solid heterogeneous chest wall mass in all children at diagnosis and six had a rib lesion. Small nodular densities in the extra-pleural fat were identified in three patients at diagnosis. US, performed in three patients, excluded tumour infiltration of the lung or diaphragm, which had been suspected on CT. On MR, the lesions showed high signal intensity in T1-weighted/proton-density images and intermediate/high signal intensity in T2-weighted images compared with muscle. Minimal chest wall involvement was demonstrated in one case by MRI. Extensive necrosis of tumour mass with pseudo-cystic appearance was documented in the five patients who underwent chemotherapy. Macroscopically complete resection was performed in five patients but there was early local recurrence after surgery in two, identified by CT in one and by MR in the other. Conclusions. PNET of the chest wall should be considered in a child with a chest wall mass. CT is valuable for evaluating tumour extension at diagnosis, the effects of chemotherapy and assessing tumour recurrence after surgery. However, CT can overestimate pleural, lung or diaphragmatic infiltration, which are better evaluated by US. MR was superior to CT in the evaluation of tumour extension in one of three patients and may be considered complementary to CT, particularly in very large chest wall tumours.

The Prognostic Effect of Clinical Staging in Pancreatic Adenocarcinoma

BackgroundThe importance of pancreatic cancer staging is uncertain. The aim of this report was to evaluate the accuracy of combined standard imaging techniques in predicting the pathologic stage and to evaluate the prognostic effect of clinical staging to identify patient groups in which laparoscopy and laparotomy could be beneficial.MethodsFifty-four patients were included in this analysis. The techniques used for clinical staging were endoscopic retrograde cholangiopancreatography, abdominal computed tomographic scan, and ultrasonography. All patients underwent both clinical and surgical/pathologic staging. A comparison was performed between presurgical stage and surgical/pathologic stage. The prognostic effect of different factors on survival was evaluated with both univariate (log-rank) and multivariate (Cox) analysis.ResultsSensitivity and specificity for vascular involvement were 73.9% and 96.3%, respectively. Sensitivity and specificity for nodal involvement were 63.6% and 95.4%, respectively. A total of 33.3% of patients showed a higher than expected pathologic stage, and 3.7% showed a lower than expected pathologic stage, by comparing clinical and pathologic evaluation. A highly significant correlation was observed between clinical T stage (P = .0067) and tumor diameter (P = .0037) and patient survival. Maximal prognostic differentiation was observed by dividing patients into two groups based on imaging results: group A (favorable prognosis) and group B (unfavorable prognosis). The median survival was 25.1 and 8.0 months for group A and B, respectively. Five-year survival was 20.1% and 0%, respectively (multivariate analysis: P = .0007).ConclusionsIntegrated standard imaging studies achieved reasonable diagnostic accuracy in our analysis. A single classification based on clinical stage and tumor diameter evaluated by imaging predicts prognosis in patients with pancreatic carcinoma.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM)

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.RiassuntoLa tomografia computerizzata del cuore (CCT) è diventata uno strumento efficace in differenti contesti clinici. Lo sviluppo della tecnologia ha portato ad una progressiva espansione delle indicazioni con una concomitante riduzione della dose di radiazioni necessaria per l’esecuzione dell’indagine. Ancora oggi sono pochi i documenti delle maggiori società scientifiche internazionali che si esprimono sulle effettive modalità di utilizzo e sulle indicazioni cliniche della CCT; in particolare mancano delle linee guida complete. Questo documento rispecchia la visione del gruppo di lavoro della Sezione di Cardio-Radiologia della Società Italiana di Radiologia Medica in merito alle indicazioni correnti della CCT.

Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale

AIMS In 30-40% of patients with acute ischaemic stroke, the cause remains undefined (cryptogenic stroke). Contrast transoesophageal echocardiography (TEE) is considered the gold standard for patent foramen ovale (PFO) detection. Recently, however, cardiac magnetic resonance (CMR) has also been applied to detect PFO. In this study, we compared the diagnostic value of CMR and TEE in detecting PFO in a group of patients with apparently cryptogenic stroke. METHODS AND RESULTS Twenty-five patients (age 50 ± 13 years, 16 males) with apparently cryptogenic ischaemic stroke underwent contrast-enhanced TEE and contrast CMR for detection of possible PFO. Both imaging studies were performed during Valsalva manoeuvre. PFO grading results were assessed visually both for TEE and for CMR, according to the entity of contrast passage in the left atrium (grade 0 = no PFO; grades 1, 2, and 3 = mild, medium, and wide PFO, respectively). TEE detected PFO in 16 patients (64%). Contrast-enhanced CMR identified a PFO in 7 (44%) of these patients. TEE showed a grade 1 PFO in five patients, a grade 2 PFO in eight patients, and a grade 3 PFO in three patients. Of these patients, CMR failed to identify PFO in all five patients with a grade 1 PFO, in one patient with a grade 2 PFO, and one patient with grade 3 PFO according to TEE. None of the nine patients without PFO at TEE was shown to have a PFO at CMR. When compared with TEE, the present methodology of CMR had a sensitivity of 50%, specificity of 100%, negative predictive value of 31%, and a positive predictive value of 100%. CONCLUSION Our data suggest that TEE is the cornerstone imaging diagnostic test to detect and characterize PFO in patients with ischaemic stroke, and is shown to be better compared with the current CMR sequences.

Are endothelial progenitor cells mobilized by myocardial ischemia or myocardial necrosis? A cardiac magnetic resonance study

BACKGROUND In ST-elevation myocardial infarction (STEMI) patients, the main stimuli involved in endothelial progenitor cells (EPCs) mobilization are not fully understood. We aimed to assess by cardiac magnetic resonance (CMR) whether the extent of ischemic myocardium (area at risk (AAR)) or of necrotic myocardium (infarct size (IS)) can be correlated to levels of circulating EPCs. METHODS Peripheral EPCs were measured in fifteen STEMI patients at 24h after successful primary percutaneous coronary intervention (pPCI). Between two and four days after pPCI all patients underwent CMR assessment of myocardial AAR, IS, myocardial salvage (MS) and microvascular obstruction at late gadolinium enhancement CMR (LG-MVO). RESULTS CD34+/KDR+, CD34+/KDR+/CD45dim, CD34+/KDR+/CD45-, EPCs were related to extent of AAR (rho=0.51, p=0.05; rho=0.55, p=0.03; rho=0.72, p=0.002, respectively), while no relationships were detected with IS, MS or LG-MVO. CONCLUSIONS Our data show that EPCs were strongly correlated to extent of myocardial AAR, thus suggesting that progenitor cells mobilization in STEMI develops in response to myocardial ischemia and not to myocardial necrosis.

Assessment of resting perfusion defects in patients with acute myocardial infarction: comparison of myocardial contrast echocardiography, combined first-pass/delayed contrast-enhanced magnetic resonance imaging and 99mTC-sestamibi SPECT.

BackgroundInformation on the accuracy of both magnetic resonance imaging (MRI) and myocardial contrast echocardiography (MCE) for the identification of perfusion defects in patients with acute myocardial infarction is limited. We evaluated the accuracy of MRI and MCE, using Single Photon Emission Computed Tomography (SPECT) imaging as reference technique.MethodsFourteen consecutive patients underwent MCE, MRI and 99mTc-MIBI SPECT after acute myocardial infarction to assess myocardial perfusion. MCE was performed by Harmonic Power Angio Mode, with end-systolic triggering 1:4, using i.v. injection of Levovist®. First-pass and delayed enhancement MRI was obtained after i.v administration of Gadolinium-DTPA. At MCE, homogeneous perfusion was considered as normal and absent or “patchy” perfusion as abnormal. At MRI, homogenous contrast enhancement was defined as normal whereas hypoenhancement at first-pass followed by hyperenhancement or persisting hypoenhancement in delayed images was defined as abnormal.ResultsAt MCE 153 (68%) of segments were suitable for analysis compared to 220 (98%) segments at MRI (p<0.001). Sensitivity, specificity and accuracy of MCE for segmental perfusion defects in these 153 segments were 83, 73 and 77%, respectively. Sensitivity, specificity and accuracy of MRI were 63, 82, and 77%, respectively. MCE and MRI showed a moderate agreement with SPECT (k: 0.52 and 0.46, respectively). The agreement between MCE and MRI was better (k: 0.67) that the one of each technique with SPECT.ConclusionMCE and MRI may be clinically useful in the assessment of perfusion defects in patients with acute myocardial infarction, even thought MCE imaging may be difficult to obtain in a considerable proportion of segments when the Intermittent Harmonic Angio Mode is used.

Right ventricular substrate mapping using the Ensite Navx system: Accuracy of high-density voltage map obtained by automatic point acquisition during geometry reconstruction

BACKGROUND Contact point-to-point electroanatomic mapping (Pt-Map) is a validated tool to evaluate right ventricular (RV) substrate. When using the EnSite NavX system (St. Jude Medical, St Paul, Minnesota), geometry reconstruction by dragging the mapping catheter (Geo-Map) allows for quicker acquisition of a large number of points and better definition of anatomy, but it is not validated for substrate mapping. OBJECTIVE This study evaluates the feasibility and accuracy of Geo-Map. METHODS Thirteen patients (mean age 38 +/- 12 years) with RV arrhythmias and an apparently normal heart underwent cardiac magnetic resonance imaging (MRI), Pt-Map, and Geo-Map. The 2 maps were compared in terms of mapping procedural time, radiation time, and total number of points acquired. We finally compared the number and characteristics of low-potential areas on each patients Pt-Map, Geo-Map, and cardiac MRI. RESULTS Geo-Map required significantly shorter mapping and radiation times in comparison to Pt-Map (12.4 +/- 4.6 vs. 31.9 +/- 10.1 and 5.8 +/- 2.1 vs. 12.1 +/- 3.9, P <.001). Furthermore, Geo-Map was based on a significantly higher density of points in comparison to Pt-Map (802 +/- 205 vs. 194 +/- 38, P <.001). Taking into consideration the total number of RV regions analyzed, the Pt-Map and Geo-Map disagreed in 2 of 65 (3%) regions (P = NS), which only Geo-Map identified as low-potential areas and indeed corresponded to wall motion abnormalities on MRI. CONCLUSION Voltage maps obtained through RV geometry acquisition have accuracy comparable to that of conventional point-by-point mapping in detecting low-voltage areas, have a good correlation with MRI wall motion abnormalities, and allow a significant reduction in procedural time and x-ray exposure.

Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.RiassuntoLa risonanza magnetica cardiaca (RMC) è considerata oggi utile nella valutazione di numerose cardiopatie. Sulla base della nostra esperienza e di quanto già pubblicato in letteratura, abbiamo preparato un documento che si propone come strumento d’indirizzo all’uso clinico della RMC. In modo sintetico si descrivono le differenti cardiopatie e si esprime per ciascuna una classe di indicazione, da I a IV, in funzione della rilevanza delle informazioni diagnostiche aspettate.Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected. Riassunto

Spontaneous Left Atrial Dissection and Hematoma Mimicking a Cardiac Tumor Findings From Echocardiography, Cardiac Computed Tomography, Magnetic Resonance Imaging, and Pathology

59-year-oldwomanwithnohistoryofcardiacsurgeryorthoracic trauma presented to the emergency departmentwith tachycardia and dyspnea. The ECG showed sinusrhythm (110 bpm). X-rays showed interstitial pulmonaryedema. Transthoracic echocardiography revealed a mild en-largement of the left atrium (LA), normal left ventricularfunction,andalargefixedmassoccupyingalmostentirelytheLA and arriving just near the posterior mitral annulus.Moderate mitral regurgitation was present. Transesophagealechocardiography confirmed the presence of an inhomoge-neous cyst-like mass with a thin hyperechogenic wall comingfrom the posterolateral wall of the LA and involving theinteratrial septum roof (Movie). Cardiac computed tomogra-phy and gadolinium-enhanced magnetic resonance imagingwere also performed (Figure).On the basis of the findings of the 3 techniques, apresumptive diagnosis of LA tumor was made and a cardiacoperation was performed with institution of cardiopulmonarybypass. A vertical extended transseptal incision was madeand an intramural mass was found in the posterior wall of theLA bulging into and occupying two thirds of the cavity.Macroscopically, no sign of infiltration was found in andoutside the LA wall, and no pericardial adhesions wereobserved. The endocardium was cut and a several clots werespread out from a non-capsulated cavity delimited by gray,fibrous, and atrophic tissue. The histopathological examina-tion showed that the mass consisted of fibrin, erythrocytes,and scattered leukocytes.The postoperative course was uneventful and the patientwas discharged on the seventh day. Repeat echocardiographyover the following months showed normal LA withoutresidual hematoma or dissection and residual mild mitralinsufficiency.SpontaneoushematomaisaveryrareA 59-year-old woman with no history of cardiac surgery or thoracic trauma presented to the emergency department with tachycardia and dyspnea. The ECG showed sinus rhythm (110 bpm). X-rays showed interstitial pulmonary edema. Transthoracic echocardiography revealed a mild enlargement of the left atrium (LA), normal left ventricular function, and a large fixed mass occupying almost entirely the LA and arriving just near the posterior mitral annulus. Moderate mitral regurgitation was present. Transesophageal echocardiography confirmed the presence of an inhomogeneous cyst-like mass with a thin hyperechogenic wall coming from …