Olov Duvernoy

Distribution of Coronary Artery Stenosis After Radiation for Breast Cancer

PURPOSE To study distribution of coronary artery stenosis among patients with breast cancer (BC) and to assess correlation between radiotherapy (RT) and location of stenosis. PATIENTS AND METHODS A Swedish BC cohort diagnosed from 1970 to 2003 was linked to registers of coronary angiography from 1990 to 2004, which yielded 199 patients. Stenoses of the coronary arteries were graded from 0 to 5, where 0 indicated a normal vessel and 5 indicated occlusion. Two hotspot areas for radiation were defined: proximal right coronary artery (prox RCA), mid and distal left anterior descending artery and distal diagonal (mdLAD + dD). RT regimens were categorized as high or low risk of irradiating the hotspot areas. Left breast/chest wall was considered high risk for mdLAD + dD; left internal mammary chain (IMC), high risk for prox RCA and mdLAD + dD from 1970 to 1995 and thereafter solely for mdLAD + dD; and right IMC, high risk for prox RCA. Other RT targets and no RT were considered low risk. Results were expressed in odds ratios (ORs) and 95% CIs. RESULTS For irradiated left- versus right-sided BC, the OR for grade 3 to 5 stenosis in mdLAD + dD was 4.38 (95% CI, 1.64 to 11.7), and for grade 4 to 5 stenosis, the OR was 7.22 (95% CI, 1.64 to 31.8). For high-risk RT versus low-risk or no RT, the OR for grade 3 to 5 stenosis in hotspot areas was 1.90 (95% CI, 1.11 to 3.24). CONCLUSION An increase of stenosis in mdLAD + dD in irradiated left-sided BC and an association between high-risk RT and stenosis in hotspot areas for radiation indicate a direct link between radiation and location of coronary stenoses.

Cardiac Imaging to Evaluate Left Ventricular Diastolic Function

Left ventricular diastolic dysfunction in clinical practice is generally diagnosed by imaging. Recognition of heart failure with preserved ejection fraction has increased interest in the detection and evaluation of this condition and prompted an improved understanding of the strengths and weaknesses of different imaging modalities for evaluating diastolic dysfunction. This review briefly provides the pathophysiological background for current clinical and experimental imaging parameters of diastolic dysfunction, discusses the merits of echocardiography relative to other imaging modalities in diagnosing and grading diastolic dysfunction, summarizes lessons from clinical trials that used parameters of diastolic function as an inclusion criterion or endpoint, and indicates current areas of research.

Complications of Percutaneous Pericardiocentesis under Fluoroscopic Guidance

Complications in 352 cases of fluoroscopy-guided percutaneous pericardiocentesis accomplished through an indwelling catheter were reviewed following surgery and non-surgery. Thirteen major complications were found, namely 3 cardiac perforations, 2 cardiac arrhythmias, 4 cases of arterial bleeding, 2 cases of pneumothorax in children, one infection, and one major vagal reaction. No significant difference in complications was found between pericardiocenteses for pericardial effusions after cardiac surgery (n = 208) and those for effusions of non-surgical (n = 144) origin. Fluoroscopy-guided pericardiocentesis by the subxiphoid approach with placement of an indwelling catheter is a safe method for achieving pericardial drainage in both surgical and non-surgical effusions. Accidental cardiac perforation with a fine needle is a minor complication as long as the needle is directed towards the anterior diaphragmatic border of the right ventricle and drainage is achieved with a reliable indwelling catheter.

Epicardial Fat Causing Pitfalls in CT and MR Imaging of the Pericardium

To study the complex anatomy of the pericardium and the pericardial recesses, notably the transverse sinus and the recess behind and under the common pulmonary artery, cryomicrotomy sections of 4 frozen cadaver specimens were correlated with CT and MR imaging in multiple planes. In addition, CT chest studies of 254 patients and MR chest studies from 78 patients were reviewed. Epicardial fat interposed between the transverse sinus of the pericardium and the ascending aorta was a normal finding confirmed by cryomicrotomy studies and seen by CT in 23 of 245 patients and in MR imaging in 3 of 78 patients. Epicardial fat indenting the pericardial sac below the common pulmonary artery caused an inhomogeneous signal, mimicking lymphadenopathy on coronal T1 weighted MR images in 4 patients.

Pericardial Effusion and Pericardial Compartments after Open Heart Surgery: An Analysis by Computed Tomography and Echocardiography

Thirty-three patients with pericardial effusion after open heart surgery were investigated with computed tomography (CT). Twelve of the 33 patients also underwent echocardiography prior to pericardiocentesis. The effusions were typed according to the results of the CT investigation. Because of postoperative adhesions, typical patterns of localized pericardial effusions were found in 16 patients. The localized compartments were seen on the right and left side of the heart and around the aorta and the pulmonary artery. CT was therefore shown to be of value for selecting the approach for drainage with catheter pericardiocentesis.

Radiation dose distribution in coronary arteries in breast cancer radiotherapy.

Abstract Background: Women irradiated for left-sided breast cancer (BC) have an increased risk of coronary artery disease compared to women with right-sided BC. We describe the distribution of radiation dose in segments of coronary arteries in women receiving adjuvant radiotherapy (RT) for left- or right-sided BC. Material and methods: Fifteen women with BC, seven left-sided and eight right-sided, who had received three-dimensional conformal radiotherapy (3DCRT), constituted the study base. The heart and the segments of the coronary arteries were defined as separate organs at risk (OAR), and the mean and maximum radiation doses were calculated for each OAR. Results: In women with left-sided BC, irrespective of if regional lymph node RT was given or not, maximum dose in mid and distal left anterior descending artery (mdLAD) was approximately 50 Gy in 6/7 patients, whereas women with right-sided BC mainly received low doses of radiation. In women with left-sided BC, 6/7 patients had substantially higher mean dose to the distal LAD than to the heart, ranging from 30 to 55 Gy and 3 to13 Gy, respectively. Conclusion: We found a pronounced difference of radiation dose distribution in the coronary arteries between women with left- and right-sided BC. Women with left-sided BC had almost full treatment dose in parts of mdLAD, regardless of if regional lymph node irradiation was given or not, while women with right-sided BC mainly received low doses to the coronary arteries.

Unrecognized Myocardial Infarction Assessed by Cardiac Magnetic Resonance Imaging - Prognostic Implications

Background Clinically unrecognized myocardial infarctions (UMI) are not uncommon and may be associated with adverse outcome. The aims of this study were to determine the prognostic implication of UMI in patients with stable suspected coronary artery disease (CAD) and to investigate the associations of UMI with the presence of CAD. Methods and Findings In total 235 patients late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging and coronary angiography were performed. For each patient with UMI, the stenosis grade of the coronary branch supplying the infarcted area was determined. UMIs were present in 25% of the patients and 67% of the UMIs were located in an area supplied by a coronary artery with a stenosis grade ≥70%. In an age- and gender-adjusted model, UMI independently predicted the primary endpoint (composite of death, myocardial infarction, resuscitated cardiac arrest, hospitalization for unstable angina pectoris or heart failure within 2 years of follow-up) with an odds ratio of 2.9; 95% confidence interval 1.1–7.9. However, this association was abrogated after adjustment for age and presence of significant coronary disease. There was no difference in the primary endpoint rates between UMI patients with or without a significant stenosis in the corresponding coronary artery. Conclusions The presence of UMI was associated with a threefold increased risk of adverse events during follow up. However, the difference was no longer statistically significant after adjustments for age and severity of CAD. Thus, the results do not support that patients with suspicion of CAD should be routinely investigated by LGE-CMR for UMI. However, coronary angiography should be considered in patients with UMI detected by LGE-CMR. Trial Registration ClinicalTrials.gov NTC01257282

Unrecognized myocardial infarctions detected by cardiac magnetic resonance imaging are associated with cardiac troponin I levels

BACKGROUND Both unrecognized myocardial infarction (UMI) and elevated levels of biomarkers are common in patients with stable coronary artery disease (CAD). The objective of this study was to determine the association between levels of cardiac biomarkers, UMI and extent of CAD in patients with stable CAD. METHODS A total of 235 patients (median age: 65years; 34% women) with stable CAD without previously known myocardial infarction were examined with late gadolinium enhancement cardiovascular magnetic resonance imaging and coronary angiography. Blood samples were drawn at enrolment and high sensitivity cardiac troponin I (cTnI), NT-proBNP and Galectin-3 were analyzed. RESULTS UMI was detected in 58 patients (25%). The median levels of cTnI, NT-proBNP and Galectin-3 were significantly higher in patients with UMI compared to those without, (p<0.001, p=0.006 and p=0.033, respectively). After adjustment for cardiovascular risk factors, left ventricular ejection fraction and renal function, cTnI remained independently associated with the presence of UMI (p=0.031) and the extent of CAD (p=0.047). Neither NT-proBNP, nor Galectin-3, was independently associated with UMI or extent of CAD. CONCLUSIONS The independent association between levels of cTnI and UMI indicates a common pathophysiological pathway for the cTnI elevation and development of UMI. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT01257282).

Pericardial Effusion and Pericardial Compartments after Open Heart Surgery

Thirty-three patients with pericardial effusion after open heart surgery were investigated with computed tomography (CT). Twelve of the 33 patients also underwent echocardiography prior to pericardiocentesis. The effusions were typed according to the results of the CT investigation. Because of postoperative adhesions, typical patterns of localized pericardial effusions were found in 16 patients. The localized compartments were seen on the right and left side of the heart and around the aorta and the pulmonary artery. CT was therefore shown to be of value for selecting the approach for drainage with catheter pericardiocentesis.

Unrecognized myocardial infarction assessed by cardiac magnetic resonance imaging is associated with adverse long-term prognosis

Background Unrecognized myocardial infarctions (UMIs) are common. The study is an extension of a previous study, aiming to investigate the long-term (>5 year) prognostic implication of late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) detected UMI in patients with suspected stable coronary artery disease (CAD) without previously diagnosed myocardial infarction (MI). Methods In 235 patients with suspected stable CAD without previous MI, LGE-CMR imaging and coronary angiography were performed. LGE with a subendocardial component detectable in more than one imaging plane was required to indicate UMI. The stenosis grade of the coronary arteries was determined, including in the artery supplying an infarcted area. Stenosis ≥70% stenosis was considered significant. Patients were followed for 5.4 years in mean regarding a composite endpoint of cardiovascular death, MI, hospitalization due to heart failure, stable or unstable angina. Results UMI were present in 58 of 235 patients (25%). Thirty-nine of the UMIs were located downstream of a significant coronary stenosis. During the follow-up 40 patients (17.0%) reached the composite endpoint. Of patients with UMI, 34.5% (20/58) reached the primary endpoint compared to 11.3% (20/177) of patients with no UMI (HR 3.7, 95% CI 2.0–6.9, p<0.001). The association between UMI and outcome remained (HR 2.3, 95% CI 1.2–4.4, p = 0.012) after adjustments for age, gender, extent of CAD and all other variables univariate associated with outcome. Sixteen (41%) of the patients with an UMI downstream of a significant stenosis reached the endpoint compared to four (21%) patients with UMI and no relation to a significant stenosis (HR 2.4, 95% CI 0.8–7.2, p = 0.12). Conclusion The presence of UMI was independently associated with an increased risk of cardiovascular events during long-term follow up.