Riccardo Faletti

Good Prognosis for Pericarditis With and Without Myocardial Involvement Results From a Multicenter, Prospective Cohort Study

Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P<0.001). Troponin elevation was not associated with an increase in complications. Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P <0.001). Troponin elevation was not associated with an increase in complications. Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting. # Clinical Perspective {#article-title-31}

Left atrial appendage morphology and silent cerebral ischemia in patients with atrial fibrillation

BACKGROUND Left atrial appendage (LAA) is the major source of cardiac thrombi in atrial fibrillation (AF) and plays a major role in cardioembolic events. OBJECTIVE To investigate the correlation between LAA morphology and the burden of silent cerebral ischemia (SCI) as a new thromboembolic risk marker in patients with AF. METHODS A total of 348 patients with AF undergoing transcatheter ablation were enrolled. A cerebral magnetic resonance (MR) was performed to assess SCI burden, while LAA morphology was studied by MR or computed tomography and categorized as follows: cactus in 52 (14.9%) patients, chicken wing in 177 (50.9%), wind sock in 101 (29.0%), and cauliflower in 18 (5.2%). RESULTS SCIs were detected in 295 (84.8%) patients, with a median number of lesions of 23. SCI burden was related to LAA complexity: 30.8% and 17.3% patients with cactus, 30.5% and 22.0% with chicken wing, 13.9% and 27.7% with wind sock, and 16.7% and 38.9% with cauliflower LAA morphologies were in the first and fourth quartiles of number of SCI per patient, respectively (P = .035). After adjustment for potential confounders, only age (β 0.12; 95% CI 0.08-0.16; P < .001), chicken wing (β -0.28; 95% CI -0.51 to -0.04; P = .021), wind sock (β 0.38; 95% CI 0.12-0.65; P = .005), and cauliflower (β 0.61; 95% CI 0.07-1.14; P = .026) LAA morphologies were significantly related to SCI burden. CONCLUSION LAA morphology relates to the burden of SCI in AF patients. Future research should corroborate if accessible methods (eg, echocardiography) are able to describe LAA morphology, permitting its use within universal thromboembolic risk predictors in AF patients.

Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer

BACKGROUND An approach based on multiparametric magnetic resonance imaging (mpMRI) might increase the detection rate (DR) of clinically significant prostate cancer (csPCa). OBJECTIVE To compare an mpMRI-based pathway with the standard approach for the detection of prostate cancer (PCa) and csPCa. DESIGN, SETTING, AND PARTICIPANTS Between November 2014 and April 2016, 212 biopsy-naïve patients with suspected PCa (prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results) were included in this randomized clinical trial. Patients were randomized into a prebiopsy mpMRI group (arm A, n=107) or a standard biopsy (SB) group (arm B, n=105). INTERVENTION In arm A, patients with mpMRI evidence of lesions suspected for PCa underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy (TB) (n=81). The remaining patients in arm A (n=26) with negative mpMRI results and patients in arm B underwent 12-core SB. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study; the secondary end point was comparison of the DR between TB and SB. RESULTS AND LIMITATIONS The overall DRs were higher in arm A versus arm B for PCa (50.5% vs 29.5%, respectively; p=0.002) and csPCa (43.9% vs 18.1%, respectively; p<0.001). Concerning the biopsy approach, that is, TB in arm A, SB in arm A, and SB in arm B, the overall DRs were significantly different for PCa (60.5% vs 19.2% vs 29.5%, respectively; p<0.001) and for csPCa (56.8% vs 3.8% vs 18.1%, respectively; p<0.001). The reproducibility of the study could have been affected by the single-center nature. CONCLUSIONS A diagnostic pathway based on mpMRI had a higher DR than the standard pathway in both PCa and csPCa. PATIENT SUMMARY In this randomized trial, a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging (mpMRI) was compared with the standard pathway based on random biopsy. The mpMRI-based pathway had better performance than the standard pathway.

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.

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

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.

Prostate Cancer Detection Rate with Koelis Fusion Biopsies versus Cognitive Biopsies: A Comparative Study

Objective: Targeted fusion biopsies have led to an improved prostate cancer (PCa) detection rate (CDR). Our aim was to assess if device-assisted fusion biopsies are superior to cognitive ones in terms of CDR. The association between multiparametric MRI parameters and PCa was also evaluated. Methods: We retrospectively enrolled 50 patients who underwent transrectal biopsy with elastic fusion (Koelis; group KB, n = 25) or cognitive approach (group CB, n = 25). Targeted biopsies were done on targets, while a variable number of random biopsies were performed depending on the clinical case. Results: The groups did not significantly differ in terms of age, prostate-specific antigen, prostate volume and previous biopsies. Mean number of random cores was significantly inferior in KB group (8.4 vs. 12.1) and mean number of targeted biopsies was significantly higher (3.6 vs. 2.6). CDR was higher in fusion biopsies (64 vs. 40%), with the gap becoming significant when considering CDR of MRI targets only (59 vs. 27%). The difference was marked for lesions ≤10 mm, where CDR was 52% in KB against 21% in CB group. Conclusions: According to our study, elastic fusion biopsies performed with Koelis achieve an increased per-patient and per-lesion CDR as compared to cognitive biopsies, especially in the case of lesions ≤10 mm.

Interventional procedures for biliary drainage with bilioplasty in paediatric patients: dosimetric aspects

Purpose . This study was undertaken to evaluate patient dose in paediatric liver transplant recipients treated by percutaneous biliary drainage and bilioplasty proceduresMaterials and methods . Effective dose rates and entrance skin-dose (ESD) rates per minute of fluoroscopy were measured by using a plexiglas phantom (thickness 10 cm) simulating the patient and by varying the exposure parameters (type of pulsed fluoroscopy, image intensifier diameter, presence of diaphragms) to identify the technique delivering the lowest patient dose. In vivo measurements were performed during three interventional proceduresResults . The effective dose rate proved to be lowest for a particular type of pulsed fluoroscopy, with maximum magnification and with field-limiting diaphragms. The in vivo measurements showed a maximum ESD value of around 50 mGy (the threshold for transient erythema is 2,000 mGy, ICRP 60). The effective dose values were in the range of 0.9–1.5 mSvConclusions . We established exposure parameters providing the desired image quality with the lowest dose for the equipment used and for a specific type of interventional procedure. The measured ESD values allow us to exclude the risk of deterministic effects on the skin. The effective dose values and considerations regarding the likelihood of radiation-induced cancer led to the conclusion that the radiological risk for the patient is largely justified by the benefits of these kinds of procedureRiassuntoObiettivo . Valutazione della dose al paziente per procedure di drenaggio biliare e bilioplastica percutanea in pazienti pediatrici trapiantati di fegatoMateriali e metodi . Sono stati misurati i ratei di dose efficace e di dose superficiale in ingresso (ESD) per minuto di scopia, simulando la presenza del paziente con fantoccio in plexiglass di 10 cm di spessore e variando i parametri di esposizione (tipo di scopia pulsata, diametro IB, presenza di diaframmi) al fine di individuare le modalità che consentono di minimizzare la dose. Nel corso di tre procedure sono state effettuate misure in vivoRisultati . I valori di rateo di dose efficace sono risultati minimi per un particolare tipo di scopia pulsata, per il massimo ingrandimento e in presenza di diaframmatura. I risultati delle misure in vivo mostrano un valore massimo di ESD di circa 50 mGy (valore soglia per eritema temporaneo 2000 mGy, ICRP 60). I valori di dose efficace sono compresi tra 0,9 e 1,5 mSvConclusioni . Sono stati stabiliti i parametri di esposizione che consentono di ottenere la qualità di immagine desiderata con la minima dose, per l’apparecchiatura utilizzata e per questa tipologia di procedure. I valori di ESD misurati permettono di escludere il rischio di insorgenza di danni deterministici alla cute. I valori di dose efficace e le considerazioni conseguenti relative alla probabilità di induzione di tumori letali consentono di affermare che i benefici associati a questo tipo di procedure giustificano ampiamente l’esposizione del paziente al rischio radiologico associato

Cardiovascular magnetic resonance as a reliable alternative to cardiovascular computed tomography and transesophageal echocardiography for aortic annulus valve sizing

To assess the accuracy and reproducibly of cardiovascular magnetic resonance (CMR) in the measurement of the aortic annulus and in process of valve sizing as compared to intra-operative sizing, cardiovascular computed tomography (CCT) and transesophageal echocardiography (TEE). Retrospective study on 42 patients who underwent aortic valve replacement from September 2010 to September 2015, with available records of pre surgery annulus assessment by CMR, CCT and TEE and of peri-operative assessment. In CCT and CMR, the annular plane was considered a virtual ring formed by the lowest hinge points of the valvular attachments to the aorta. In TEE the annulus was measured at the base of leaflet insertion in the mid-esophageal long-axis view using the X-plane technique. Two double-blinded operators performed the assessments for each imaging technique. Intra-operative evaluation was performed using Hegar dilators. Continuous variables were studied with within-subject ANOVA, Bland–Altman (BA) plots, Wilcoxon’s and Friedman’s tests; trends were explored with scatter plots. Categorical variables were studied with Fisher’s exact test. The intra- and inter-operator reliability was satisfying. There were no significant differences between the annulus dimensions measured by CMR and either one of the three references. Valve sizing for CoreValve by CMR had the same good agreement with CCT and TEE, with a 78 % match rate; for SAPIEN XT the agreement was slightly better (82 %) for CCT than for TEE (66 %). MR performs well when compared to the surgical reference of intra-operative sizing and stands up to the level of the most used imaging references (CCT and TEE).

Lights and shadows of cardiac magnetic resonance imaging in acute myocarditis

AbstractCardiac magnetic resonance (CMR) is considered a primary tool for the diagnosis of acute myocarditis, due to its unique potential for non-invasive identification of the various hallmarks of the inflammatory response, with relevant impact on patient management and prognosis. Nonetheless, a marked variation in sensitivity and negative predictive value has been reported in the literature, reflecting the intrinsic drawbacks of current diagnostic criteria, which are based mainly on the use of conventional CMR pulse sequences. As a consequence, a negative exam cannot reliably exclude the diagnosis, especially in patients who do not present an infarct-like onset of disease. The introduction of new-generation mapping techniques further widened CMR potentials, allowing quantification of tissue changes and opening new avenues for non-invasive workup of patients with inflammatory myocardial disease.Main messages• CMR sensitivity varies in AM, reflecting its clinical polymorphism and the intrinsic drawbacks of LLc. • Semiquantitative approaches such as EGEr or T2 ratio have limited accuracy in diffuse disease forms. • T1 mapping allows objective quantification of inflammation, with no need to normalize measurements. • A revised protocol including T2-STIR, T1 mapping and LGE could be hypothesized to improve sensitivity.