Rocco Donato

Right Ventricular Ischemic Injury in Patients With Acute ST-Segment Elevation Myocardial Infarction. Characterization With Cardiovascular Magnetic Resonance

Background— Experimental data show that the right ventricle (RV) is more resistant to ischemia than the left ventricle. To date, limited data are available in humans because of the difficulty of discriminating reversible from irreversible ischemic damage. We sought to characterize RV ischemic injury in patients with reperfused myocardial infarction using cardiovascular magnetic resonance. Methods and Results— In 3 tertiary centers, 242 consecutive patients with reperfused acute ST-segment elevation myocardial infarction were studied with cardiovascular magnetic resonance at 1 week and 4 months after myocardial infarction. T2-weighted and postcontrast cardiovascular magnetic resonance scans were used to depict myocardial edema and late gadolinium enhancement, respectively. Early after infarction, RV edema was common (51% of patients), often associated with late gadolinium enhancement (31% of patients). Remarkably, RV edema and late gadolinium enhancement were found in 33% and 12% of anterior left ventricular infarcts, respectively. Baseline regional and global RV functions were inversely related to the presence and extent of RV edema and RV late gadolinium enhancement. At follow-up, a significant decrease in frequency (25/242 patients; 10%) and extent of RV late gadolinium enhancement was observed (P<0.001). With the use of multivariable analysis, the presence of RV edema was an independent predictor of RV global function improvement during follow-up (&bgr;-coefficient=0.221, P=0.003). Conclusions— Early postinfarction RV ischemic injury is common and is characterized by the presence of myocardial edema, late gadolinium enhancement, and functional abnormalities. RV injury is not limited to inferior infarcts but is commonly found in anterior infarcts as well. Cardiovascular magnetic resonance findings suggest reversibility of acute RV dysfunction with limited permanent myocardial damage at 4-month follow-up.

Dual-Source Dual-Energy CT Evaluation of Complex Cystic Renal Masses

OBJECTIVE The purpose of this study was to assess the value of dual-source dual-energy CT in the evaluation of complex cystic renal masses. SUBJECTS AND METHODS Seventy patients underwent contrast-enhanced dual-energy CT that included true unenhanced images acquired in single-energy mode, corticomedullary phase images acquired in dual-energy mode, and nephrographic phase images acquired in single-energy mode. Virtual unenhanced, blended weighted-average, and color-coded iodine overlay images were reconstructed. The acceptance level and image quality of virtual and true unenhanced images were evaluated. Contrast enhancement on both true unenhanced or blended weighted-average images and color-coded iodine overlay images was evaluated with both calculation in regions of interest and use of confidence level scales. Radiation dose parameters were estimated. RESULTS Virtual unenhanced images of 70 lesions (97.2%) and true unenhanced images of 72 lesions (100%) were judged acceptable (p = 0.5). The mean quality score of virtual unenhanced images was 2.0 ± 0.7 and of true unenhanced images was 1.5 ± 0.5 (p < 0.001). Mean contrast enhancement measured on true unenhanced and blended weighted-average images was 45.9 ± 15.9 HU (range, 21-78 HU) and on color-coded iodine overlay images was 47.3 ± 16.8 HU (range, 22-75 HU) with no significant differences. Enhancement was excluded on color-coded iodine overlay images with a significantly (p < 0.03) higher level of confidence than it was on true unenhanced and blended weighted-average images. The mean dose reduction with use of a combined dual- and single-energy dual-phase CT protocol was 29.1% ± 11.9% (p < 0.001). CONCLUSION Dual-source dual-energy CT is a reliable imaging technique in the evaluation of complex cystic renal masses. True unenhanced images can be replaced by virtual unenhanced images with considerable radiation dose reduction. The color-coded iodine overlay technique is a useful tool for both excluding and identifying endocystic enhancement.

Contrast-enhancing right atrial thrombus in cancer patient

The progress in cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–11]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care. Increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention [12,13] as well as the role of the thromboembolism prophylaxis [14–24]. The increased thromboembolism risk in cancer patients [19,20] is influenced by the type of cancer, its stage and histology, the presence of thrombophilia, concomitant and previous treatments, metastatic-stage malignancy [25], vascular catheter presence [15], and paraneoplastic hypercoagulability [17,18,20,25]. Patient-, cancer-, and treatment-related factors should be taken under consideration in the assessment of individual venous thromboembolism risk [25]. We present a case of a right atrial mass in a 57-year-old Italian woman. She reported a history of diabetes mellitus, a history of smoking, a sotalol treatment and a lymphoma chemotherapy treatment. Echocardiographic evaluation revealed a right atrial mass (Fig. 1) [26,27]. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network [26]. Cardiac magnetic resonance [27,28] identified right atrial mass as an atrial thrombus

Comparison Between 99mTc-Diphosphonate Imaging and MRI With Late Gadolinium Enhancement in Evaluating Cardiac Involvement in Patients With Transthyretin Familial Amyloid Polyneuropathy

OBJECTIVE Cardiac involvement is not rare in systemic amyloidosis and is associated with poor prognosis. Both (99m)Tc-diphosphonate imaging and cardiac MRI with late gadolinium enhancement are considered valuable tools in revealing amyloid deposition in the myocardium; however, to our knowledge, no comparative study between the two techniques exists. We compared findings of these two techniques in patients with transthyretin-familial amyloid polyneuropathy (FAP). SUBJECTS AND METHODS Eighteen patients with transthyretin-FAP underwent (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement. Images were visually evaluated by independent readers to determine the presence of radiotracer accumulation or late gadolinium enhancement-positive areas at the level of cardiac chambers. RESULTS Interobserver agreement ranged from moderate to very good for (99m)Tc-diphosphonate imaging findings and was very good for findings of MRI with late gadolinium enhancement. Left ventricle (LV) radiotracer uptake was found in 10 of 18 patients, whereas LV late gadolinium enhancement-positive areas were found in eight of 18 patients (χ(2) = 0.9; p = 0.343). One hundred fifty-nine LV segments showed (99m)Tc-diphosphonate accumulation, and 57 LV segments were late gadolinium enhancement positive (p < 0.0001). Radiotracer uptake was found in the right ventricle (RV) in eight patients and in both atria in five patients, whereas MRI showed that RV was involved in three patients and both atria in six patients; the differences were not statistically significant (RV, p = 0.07; atria, p = 1). Intermodality agreement between (99m)Tc-diphosphonate imaging and MRI ranged from fair to good. CONCLUSION Our study shows that, although (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement have similar capabilities to identify patients with myocardial amyloid deposition, cardiac amyloid infiltration burden can be significantly underestimated by visual analysis of MRI with late gadolinium enhancement compared with (99m)Tc-diphosphonate imaging.

Cardioinhibitory vasovagal syncope in a cancer patient

The progress in cancer knowledge and treatment has led to a new frontier: cardio-oncology [1–27]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care [1,12,17]. We present a case of a 57year-old Italian man complaining about episodes of cardioinhibitory vasovagal syncope [28–30]. He reported a history of atrial fibrillation, diabetes mellitus, smoking, a sotalol treatment, a chemotherapy treatment and a laryngeal tracheostomy for laryngeal cancer. Echocardiographic evaluation revealed a biatrial dilatation, a fibrocalcification of a three-leaflet aortic valve with a severe aortic stenosis [AVA = 0.8 cm, transvalvular mean gradient = 51 mm Hg] [Fig. 1] and a moderate aortic regurgitation [PHT= 415ms], and amildmitral regurgitation. Results of a 24-hour Holter monitoring showed several pauses of at least 1.5 s and up to 2.5 s, and 68 pauses of longer than 2.5 s (max pause of 3360 ms). Computer tomography imaging showed progressive stenosis of the left internal carotid artery and the total occlusion of the left jugular vein due to neck neoplastic mass [Fig. 2]. A pacemaker implantation was successfully performed.

Guide to magnetic resonance in Crohn's disease: From common findings to the more rare complicances

Considering that multiple imaging examinations are often necessary for monitoring Crohns disease (CD) activity and severity in order to guide and monitor appropriate treatment, the ideal imaging test would be reproducible, well tolerated by patients, and free of ionizing radiation. For these reasons recent studies have highlighted the role of a magnetic resonance imaging (MRI) technique optimized for small bowel imaging in the evaluation of small bowel disorders. In this regard there are two main methodological approaches represented by MR enterography, following administration of an oral contrast medium, and MR enteroclysis, following administration of contrast medium through a nasojejuneal tube. MRI may be used to demonstrate the pathologic findings and complications of CD. In particular, MR has excellent sensitivity and specificity, ranging from 88%-98% and 78%-100%, respectively, for the detection of active inflammation, wall thickening, ulcerations, increased wall enhancement, increased vascularity, perienteric inflammation, and reactive adenopathy. MR also allows more accurate identification of associated complications including penetrating and fibrostenotic disease as well as the more rare extraintestinal manifestations that are usually associated with severe and longstanding intestinal inflammation, the latter often guiding the therapeutic approach. In the progression of CD some rare complications can occur that, to our knowledge, were only briefly or never mentioned in the radiological literature regarding MR enterography or enteroclysis and in which the application of these techniques play a key role.

Left atrial function in cardiac amyloidosis.

Aims Left atrium can be involved by amyloid deposition in familial amyloid polyneuropathy (FAP). The aim of our study is to assess left atrium function in atrial amyloidosis. Methods Twenty-eight FAP patients (53 ± 12 years) and a control group of 22 asymptomatic individuals (49 ± 11 years) underwent strain echocardiography and cardiac magnetic resonance (CMR). CMR by late gadolinium enhancement (LGE) was used to assess the left atrium amyloid deposition, whereas strain echocardiography was used to quantify the left atrium deformation. The following atrial longitudinal strain (ALS) parameters were assessed: peak at the end of ventricular systole (peak-ALS), peak at early diastole (early-ALS), negative peak in late diastole, precontraction (prec)-ALS (difference between peak-ALS and early-ALS), and late ALS (sum of negative peak and prec-ALS). Results CMR showed atrial LGE in 14 FAP patients (LGE-atrial group), whereas 14 FAP patients showed no LGE (no-LGE-atrial group). Peak-ALS was significantly lower in the LGE-atrial group (22.8 ± 13%) compared with the no-LGE-atrial group (59.6 ± 33.1%; P = 0.001) and controls (47.4 ± 16.4%; P = 0.001). Early-ALS was lower in the LGE-atrial group (10.2 ± 6.2%) compared with the controls (26.3 ± 11.9%; P = 0.02) and the no-LGE-atrial group (30.2 ± 22.4%; P = 0.01). Prec-ALS was lower (P = 0.001) in the LGE-atrial group (12.6 ± 7.8%) compared with the no-LGE-atrial group (26.2 ± 15%). Conversely, late-ALS was higher (P = 0.04) in the no-LGE-atrial group (22.8 ± 12.3%) compared with the controls (13.9 ± 9%); no significant differences were found in the negative peak among groups. Conclusions Patients with atrial amyloidosis have an adverse left atrium remodeling associated with left atrium dysfunction. Left atrium assessment may provide useful information in the clinical and prognostic stratification of amyloidotic patients.

Left Atrial Morphology, Size and Function in Patients With Transthyretin Cardiac Amyloidosis and Primary Hypertrophic Cardiomyopathy – Comparative Strain Imaging Study –

BACKGROUND We sought to assess left atrial (LA) morphology and function in patients with transthyretin cardiac amyloidosis (TTR-CA) and hypertrophic cardiomyopathy (HCM). Primarily, longitudinal deformation (reservoir) and pump function were the focus of vector-velocity strain echocardiography imaging. METHODSANDRESULTS The study group comprised 32 patients (mean age 57.7±15.4 years, 16 in each group), and 15 healthy controls. Diagnosis of TTR-CA was based on echocardiography and either gadolinium-enhanced (LGE) cardiac magnetic resonance (cMRI) or radionuclide imaging. At baseline, there were no differences in age, body surface area, blood pressure and risk factors among the groups. Left ventricular (LV) mass was greater in patients than in controls, and slight LA dilatation was found in the TTR-CA group. LA reservoir was 14.1±4.7% in TTR-CA, 20.0±5.6% in HCM, and 34.0±11.8% in controls (<0.001). In addition, LA pump function chiefly was impaired in the former group, irrespective of LA chamber size and LV ejection fraction. LGE in the atrial wall was seen in 9/10 TTR-CA versus 0/8 HCM patients undergoing cMRI (P<0.001). LA reservoir ≤19% and pump function ≤-1.1% best discriminated TTR-CA from HCM patients in the receiver-operating characteristic analysis. CONCLUSIONS LA reservoir and pump function were significantly impaired in both TTR-CA and HCM patients compared with controls, but mainly in the former group, irrespective of LA volume and LV ejection fraction, likely caused by a more altered LA wall structure. (Circ J 2016; 80: 1830-1837).

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.

A massive pericardial effusion in a cancer patient

The progress in the cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–22]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists for the optimal effective patients care [1–24]. Moreover oncosurgery represents a challenge for cardiologist [23] and preoperative cardiological assessment is the cornerstone of the modern oncosurgery as well as efficacious anesthesiological evaluation [23–25]. In the emerging scenario of concomitant problems and diseases [23–38], physicians should be familiar with available drugs, environmental epidemiology and patient factors [23–34] as well as with new emerging findings regarding use of cardiovascular drugs [26,27,30–33,39]. The pericardium is involved in a large number of systemic disorders includingneoplastic pathologies [40–73]. We present a case of massive pericardial effusion in a 66-yearold Italian man suffering from a haematological cancer. Echocardiographic evaluation revealed a massive pericardial effusion with initial signs of atrial collapse (Fig. 1). Post-contrast CT images show a massive pericardial effusion (white asterisks), with left hilar lymphadenopathies, malignant lung nodules associated with mild pleural thickening and effusion (Fig. 2 Panel A) and abdominal voluminous lymphadenopathy (Fig. 2 Panel B). Also this case is illustrative of the benefit resulting from an open dialogue between both cardiologists and oncologists for the optimal effective patients care.