Maurizio Centonze

Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice mdct imaging in patients scheduled for coronary angiography (nimiscad-non invasive multicenter italian study for coronary artery disease)

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (≥16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per-artery and per-segment basis. On-site evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85–0.95), 0.91 (95% CI 0.86–0.95), 0.94 (95% CI 0.89–0.97), 0.88 (95% CI 0.81–0.93), and 0.91 (95% CI 0.88–0.94), respectively. Off-site analysis included 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, specificity, and DA were 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), and 0.82 (95% CI 0.77–0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines.

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.

Anatomic Localization of Rapid Repetitive Sources in Persistent Atrial Fibrillation: Fusion of Biatrial CT Images With Wave Similarity/Cycle Length Maps

OBJECTIVES The aim of this study was to investigate the anatomic distribution of critical sources in patients with atrial fibrillation (AF) by fusion of biatrial computed tomography (CT) images with cycle length (CL) and wave similarity (WS) maps. BACKGROUND Experimental and clinical studies show that atrial fibrillation (AF) may originate from rapid and repetitive (RR) sources of activation. Localization of RR sources may be crucial for an effective ablation treatment. Atrial electrograms showing rapid and repetitive activations can be identified by combining WS and CL analysis. METHODS Patients with persistent AF underwent biatrial electroanatomic mapping and pre-procedural CT cardiac imaging. WS and CL maps were constructed in 17 patients by calculating the degree of repetitiveness of activation waveforms (similarity index [S]) and the cycle length at each atrial site. WS/CL maps were then integrated with biatrial 3-dimensional CT reconstructions by a stochastic approach. RESULTS Repetitive sources of activation (S ≥ 0.5) were present in most patients with persistent AF (94%) and were mainly located at the pulmonary veins (82% of patients), at the superior caval vein (41%), on the anterior wall of the right atrium (23%), and at the left atrial appendage (23%). Potential driver sources showing both rapid and repetitive activations (CL = 140.7 ± 25.1 ms, S = 0.65 ± 0.15) were present only in a subset of patients (65%) and were confined to the pulmonary vein region (47% of patients) and left atrial appendage (12%). Differently, the repetitive activity of the superior caval vein was characterized by a slow activation rate (CL = 184.7 ± 14.6 ms). CONCLUSIONS The identification and localization of RR sources is feasible by fusion of biatrial anatomic images with WS/CL maps. Potential driver sources are present only in a subset of patients with persistent AF and are mainly located in the pulmonary vein region.

Cardiac and pericardial abnormalities on chest computed tomography: what can we see?

Radiological reporting in chest computed tomography (CT) is primarily focused on assessing pulmonary and mediastinal abnormalities, thereby tending to overlook the heart. However, incidental cardiac abnormalities are often encountered and misdiagnosed, which may potentially impact the patient’s treatment or necessitate further investigation. The aim of this pictorial review is to provide a stepwise approach to assessing the heart on routine non-electrocordiographic-gated (non-ECG-gated) chest CT and describing common and less frequent cardiac abnormalities.RiassuntoIl referto radiologico di una TC del torace si focalizza soprattutto sulla rilevazione delle alterazioni del parenchima polmonare e del mediastino, mentre la valutazione del cuore viene trascurata. Tuttavia, spesso si riscontrano e vengono misinterpretate anomalie cardiache incidentali, che potrebbero avere un significativo impatto clinico e terapeutico sul paziente o che necessiterebbero di ulteriori approfondimenti diagnostici. Scopo di questa rassegna iconografica è fornire gli strumenti per un approccio ragionato al cuore negli esami TC del torace di routine, non cardiosincronizzati, descrivendo sia le anomalie cardiache più comuni sia quelle meno frequenti.

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

Role of multidetector computed tomography in the anatomical definition of the left atrium-pulmonary vein complex in patients with atrial fibrillation. Personal experience and pictorial assay

PurposeThis study aimed to illustrate the typical anatomical pattern and anatomical variants of the left atrium-pulmonary vein (LA-PV) complex studied by 16-slice multidetector computed tomography (MDCT) in a population of patients with atrial fibrillation (AF) undergoing percutaneous transcatheter left atrial ablation. Accurate knowledge of this anatomical region is fundamental for increasing the efficiency, efficacy and accuracy of the procedure and for reducing the risk of complications.Materials and methodsFrom January 2004 to March 2007, we studied 75 patients (57 men, 18 women) affected by paroxysmal and chronic AF by using MDCT. In 63 patients, the MDCT examination was performed using retrospective cardiac electrocardiographic (ECG) gating and dose modulation, with reconstructions performed at 75% of R-R interval. In the remaining 12 patients, ECG gating was not possible due to high-frequency AF.ResultsWe identified 286 PV: 157 right and 129 left. On the right side, eight PV were supernumerary and one was a common trunk, whereas on the left side, we found 22 common trunks and one supernumerary vein. In 61.3% of patients, the anatomical pattern was typical (two right and two left PV). In the remaining 38.7%, it was atypical [two right PV-left common trunk (26.6%); three right PV-two left PV (6.7%); three right PV-left common trunk (2.6%); three right PV-three left PV (1.3%); right common trunk-two left PV (1.3%)]. MDCT identified branching of the right inferior PV in 94.5%, of the right superior PV in 75.6%, of the left superior PV in 7.5% and of the left inferior PV in 7.5%; 3/8 of the right supernumerary veins presented branching. With respect to the left PV ostia, the position of the orifice of the 74 recognised appendages was high in 85.1%, intermediate in 12.1% and low in 2.8%. There was no association between PV anatomical variants and clinical presentation of AF (paroxysmal or chronic).ConclusionsMDCT represents a fundamental diagnostic imaging tool in the anatomical definition of the LA-PV complex, which is characterised by considerable variability. Radiologists must be familiar with the anatomical variants and help the referring interventional electrophysiologist understand their importance.RiassuntoObiettivoIllustrare quadro tipico e varianti anatomiche del complesso atrio sinistro-vene polmonari (AS-VP) studiato con TC spirale multidetettore a 16 strati (TCMD) in una popolazione di pazienti affetti da fibrillazione atriale (FA) in attesa di essere sottoposti ad intervento di ablazione trans-catetere in atrio sinistro. La precisa conoscenza di questa regione anatomica è indispensabile per realizzare con maggiore efficacia, efficienza ed accuratezza la procedura terapeutica, riducendo le complicanze.Materiali e metodiNel periodo compreso tra gennaio 2004 e marzo 2007 sono stati valutati con TCMD 75 pazienti (57 maschi e 18 femmine) affetti da FA parossistica e cronica. In 63 pazienti l’indagine TCMD è stata effettuata con gating cardiaco retrospettivo e modulazione della dose, ricostruendo la finestra temporale corrispondente al 75% dell’intervallo RR dell’ECG. Nei restanti 12 pazienti non è stato possibile utilizzare il gating cardiaco per la presenza di FA ad alta frequenza.RisultatiNei pazienti studiati sono state identificate 286 VP, 157 a destra e 129 a sinistra. A destra sono state riconosciute 8 vene soprannumerarie e 1 tronco comune mentre a sinistra 22 tronchi comuni e 1 vena soprannumeraria. Nel 61,3% dei pazienti il quadro inadeanatomico era tipico (2 VP destre e sinistre) e atipico nel restante 38,7% dei pazienti (26,6% 2 VP destre-tronco comune sinistro; 6,7% 3 VP destre-2 VP sinistre; 2,6% 3 VP destre-tronco comune sinistro; 1,3% 3 VP destre-3 VP sinistre; 1,3% tronco comune destro-2 VP sinistre). Nella definizione dei rami di confluenza pre-ostiali delle VP (branching), la TCMD ha identificato il branching della VP inferiore destra nel 94,5% dei casi, della VP superiore destra nel 75,6%, della VP superiore sinistra nel 7,5% e della VP inferiore sinistra nel 7,5%; 3/8 delle vene soprannumerarie destre presentavano branching. Rispetto all’ostio delle VP sinistre, l’orifizio delle 74 auricole identificate era in posizione alta nel 85,1% dei casi, in posizione intermedia nel 12,1% e bassa nel 2,8%. Non sono state rilevate associazioni tra varianti anatomiche delle VP e presentazione clinica della FA (parossistica o cronica).ConclusioniLa TCMD è uno strumento diagnostico fondamentale per definire l’anatomia del complesso AS-VP, la cui variabilità anatomica è elevata. Il radiologo deve conoscere le varianti anatomiche e farne capire l’importanza all’elettrofisiologo interventista.

A stochastic approach for automatic registration and fusion of left atrial electroanatomic maps with 3D CT anatomical images

The integration of electroanatomic maps with highly resolved computed tomography cardiac images plays an important role in the successful planning of the ablation procedure of arrhythmias. In this paper, we present and validate a fully-automated strategy for the registration and fusion of sparse, atrial endocardial electroanatomic maps (CARTO maps) with detailed left atrial (LA) anatomical reconstructions segmented from a pre-procedural MDCT scan. Registration is accomplished by a parameterized geometric transformation of the CARTO points and by a stochastic search of the best parameter set which minimizes the misalignment between transformed CARTO points and the LA surface. The subsequent fusion of electrophysiological information on the registered CT atrium is obtained through radial basis function interpolation. The algorithm is validated by simulation and by real data from 14 patients referred to CT imaging prior to the ablation procedure. Results are presented, which show the validity of the algorithmic scheme as well as the accuracy and reproducibility of the integration process. The obtained results encourage the application of the integration method in post-intervention ablation assessment and basic AF research and suggest the development for real-time applications in catheter guiding during ablation intervention.

A Novel Skeleton Based Quantification and 3-D Volumetric Visualization of Left Atrium Fibrosis Using Late Gadolinium Enhancement Magnetic Resonance Imaging

This work presents the results of a new tool for 3-D segmentation, quantification and visualization of cardiac left atrium fibrosis, based on late gadolinium enhancement magnetic resonance imaging (LGE-MRI), for stratifying patients with atrial fibrillation (AF) that are candidates for radio-frequency catheter ablation. In this study 10 consecutive patients suffering AF with different grades of atrial fibrosis were considered. LGE-MRI and magnetic resonance angiography (MRA) images were used to detect and quantify fibrosis of the left atrium using a threshold and 2-D skeleton based approach. Quantification and 3-D volumetric views of atrial fibrosis were compared with quantification and 3-D bipolar voltage maps measured with an electro-anatomical mapping (EAM) system, the clinical reference standard technique for atrial substrate characterization. Segmentation and quantification of fibrosis areas proved to be clinically reliable among all different fibrosis stages. The proposed tool obtains discrepancies in fibrosis quantification less than 4% from EAM results and yields accurate 3-D volumetric views of fibrosis of left atrium. The novel 3-D visualization and quantification tool based on LGE-MRI allows detection of cardiac left atrium fibrosis areas. This noninvasive method provides a clinical alternative to EAM systems for quantification and localization of atrial fibrosis.

Registration and fusion of segmented left atrium CT images with CARTO electrical maps for the ablative treatment of atrial fibrillation

This study aims to extract the interior surface of the left atrium (LA) and pulmonary veins (PVs) from three dimensional tomographic data and to integrate it with LA CARTO electrical maps. The separation of LA and PVs from other overlapping structures of the heart was performed processing 3D CT data by marker-controlled watershed segmentation and surface extraction. CARTO maps were then registered on the LA internal surface by a stochastic optimization algorithm based on simulated annealing. The residual registration error resulted inferior to 3 mm. The integration between electrophysiological and high resolved anatomic information of LA results feasible and may constitute a significant support for mechanism investigation and treatment of atrial fibrillation.

Italian registry of cardiac magnetic resonance

OBJECTIVES Forty sites were involved in this multicenter and multivendor registry, which sought to evaluate indications, spectrum of protocols, impact on clinical decision making and safety profile of cardiac magnetic resonance (CMR). MATERIALS AND METHODS Data were prospectively collected on a 6-month period and included 3376 patients (47.2 ± 19 years; range 1-92 years). Recruited centers were asked to complete a preliminary general report followed by a single form/patient. Referral physicians were not required to exhibit any specific certificate of competency in CMR imaging. RESULTS Exams were performed with 1.5T scanners in 96% of cases followed by 3T (3%) and 1T (1%) magnets and contrast was administered in 84% of cases. The majority of cases were performed for the workup of inflammatory heart disease/cardiomyopathies representing overall 55.7% of exams followed by the assessment of myocardial viability and acute infarction (respectively 6.9% and 5.9% of patients). In 49% of cases the final diagnosis provided was considered relevant and with impact on patients clinical/therapeutic management. Safety evaluation revealed 30 (0.88%) clinical events, most of which due to patients preexisting conditions. Radiological reporting was recorded in 73% of exams. CONCLUSIONS CMR is performed in a large number of centers in Italy with relevant impact on clinical decision making and high safety profile.