Satinder P. Singh

Idiopathic ventricular arrhythmias originating from the aortic root prevalence, electrocardiographic and electrophysiologic characteristics, and results of radiofrequency catheter ablation.

OBJECTIVES This study investigated the prevalence and electrocardiographic and electrophysiologic characteristics of aortic root ventricular arrhythmias (VAs). BACKGROUND Idiopathic VAs originating from the ostium of the left ventricle may be ablated at the base of the aortic cusps. METHODS We studied 265 patients with idiopathic VAs with an inferior QRS-axis morphology. RESULTS The successful ablation site was within (or below) the aortic cusps in 44 patients (16.6%). The site of the origin was the left coronary cusp (LCC) in 24 (54.5%), the right coronary cusp (RCC) in 14 (31.8%), the noncoronary cusp (NCC) in 1 (2.3%), and at the junction between the LCC and RCC (L-RCC) in 5 (11.4%) cases. The maximum amplitude of the R-wave in the inferior leads was significantly greater with an LCC than with an RCC origin (p < 0.05). The ratio of the R-wave amplitude in leads II and III was significantly greater with an LCC than with an RCC origin (p < 0.01) and was significantly smaller in the NCC than in the other sites (p < 0.0001). The ventricular deflection in the His bundle electrogram was significantly later relative to the surface QRS with an LCC or L-RCC origin than with an RCC or NCC origin (p < 0.0001). The ratio of the atrial-to-ventricular deflection amplitude was significantly greater in the NCC than in the other sites (p < 0.0001). No other factors predicted the site of origin. CONCLUSIONS Idiopathic VAs are more common in the LCC than in the RCC and rarely arise from the NCC. The electrocardiogram is useful for differentiating the site of origin.

CT Emphysema Predicts Thoracic Aortic Calcification in Smokers with and Without COPD

ABSTRACT COPD patients are at increased risk for cardiovascular morbidity and mortality independent of smoking habits. Recent studies suggest CT emphysema is an independent predictor of cardiovascular risk as evidenced by its association with arterial stiffness and impaired endothelial function. We examined the relationship between demographics, lung function, CT emphysema and airway wall thickness and thoracic aortic calcification, another marker of cardiovascular risk, in the National Lung Screening Trial. We hypothesized that CT emphysema would be independently associated with thoracic aortic calcification. Two hundred forty current and former smokers were enrolled. After CT examination, we recorded subjects’ demographics and they performed spirometry. Subjects were classified into COPD and non-COPD subgroups. CT emphysema was quantified as a percentage of lung volume and measurements of the right upper lobe airway were performed using standard methods and expressed as wall area (%). Total calcification scores for the thoracic aorta were computed using TeraRecon image analysis. Univariate and multivariate analyses were performed to determine the associations between calcium score and subject characteristics. Subjects with COPD were older, more often male, heavier smokers and had more CT emphysema and greater aortic calcification than those without COPD. Calcium score was associated with age, pack-years, CT emphysema, wall area%, and lung function on univariate testing but only with age and CT emphysema on multivariate analysis. We conclude that CT emphysema is independently associated with thoracic calcification and thus may be used to assess cardiovascular risk in smokers with and without COPD.

Cardiac Paraganglioma: Cardiac Paraganglioma

Cardiac paragangliomas are rare tumors arising from chromaffin cells. Two patients with cardiac paragangliomas underwent surgical resection with no evidence of recurrence three and 13 years following surgery. This report describes these two patients with cardiac paragangliomas and discusses their management. doi: 10.1111/jocs.12479 (J Card Surg 2015;30:135–139)

Use of Gated Cardiac Computed Tomography Angiography in the Assessment of Left Ventricular Assist Device Dysfunction

The purpose of this study is to describe the utility and limitations of gated contrast-enhanced cardiac computed tomography angiography in assessing left ventricular assist device function. Computed tomography angiography (CTA) was used in 14 patients with left ventricular assist devices (LVADs) who had persistent heart failure symptoms, hemodynamic instability, or potential problems with LVAD flows. Retrospectively gated contrast-enhanced CTA was performed on 64-detector scanner, and the CTA images were postprocessed in multiple curved projections on TeraRecon workstation. This study describes the use of CTA to identify LVAD-related issues that altered clinical management and explores the role of CTA and other techniques in evaluating LVAD function. Six of 14 LVAD patients who demonstrated no abnormality on CTA remained stable with medical management. In the remaining eight patients, CTA was abnormal, including abnormalities specifically related to the LVAD cannula. As a result of findings detected by CTA, six patients underwent surgical intervention, including device exchange and heart transplant. Computed tomography angiography is a noninvasive method that enhances diagnostic evaluation of patients with suspected LVAD dysfunction and can lead to changes in patient management.

CT Distinction of Interarterial and Intraseptal Courses of Anomalous Left Coronary Artery Arising From Inappropriate Aortic Sinus

AJR 2010; 194:W351–W352 0361–803X/10/1944–W351

Use of retrospectively gated CT angiography to diagnose systolic LVAD inflow obstruction.

Assessment of patients with left ventricular assist devices (LVADs) can be challenging, and multiple modalities are sometimes necessary to arrive at the accurate diagnosis. We describe two patients with persistent heart failure symptoms after HeartMate II LVAD placement. After initial evaluation was unrevealing, retrospectively gated computed tomographic angiography (CTA) was used to diagnose partial inflow obstruction, leading to important changes in management. We describe the techniques and role of retrospective gating and discuss functional assessment by CT as well as future applications.

Anomalous origin of posterior descending artery from left anterior descending artery with unusual intraseptal course.

The posterior descending artery (PDA) arises from the right coronary artery (RCA) in ~85% of people; only in from 10 to 15% does it arise from the circumflex artery. We report an unusual case of origin of the PDA from a branch of the left anterior descending artery (LAD). The PDA passed through the interventricular septum before it reached the posterior interventricular groove.

A Guide to Writing Academic Portfolios for Radiologists

The academic educators portfolio is a collection of materials that document academic performance and achievements, supplementing the curriculum vitae, in order to showcase a faculty members most significant accomplishments. A decade ago, a survey of medical schools revealed frustration in the nonuniform methods of measuring facultys medical education productivity. A proposed solution was the use of an academic educators portfolio. In the academic medical community, compiling an academic portfolio is always a challenge because teaching has never been confined to the traditional classroom setting and often involves active participation of the medical student, resident, or fellow in the ongoing care of the patient. Diagnostic radiology in addition requires a knowledge base that encompasses basic sciences, imaging physics, technology, and traditional and molecular medicine. Teaching and performing research that involves this complex mix, while providing patient care that is often behind the scenes, provides unique challenges in the documentation of teaching, research, and clinical service for diagnostic radiology faculty. An academic portfolio is seen as a way to explain why relevant academic activities are significant to promotions committee members who may have backgrounds in unrelated academic areas and may not be familiar with a faculty members work. The academic portfolio consists of teaching, research, and service portfolios. The teaching portfolio is a collection of materials that document teaching performance and documents the educators transition to a more effective educator. A research portfolio showcases the most significant research accomplishments. The service portfolio documents service responsibilities and highlight any service excellence. All portfolios should briefly discuss the educators philosophy, activities, methods used to implement activities, leadership, mentoring, or committee roles in these respective areas. Recognizing that academic programs have differing needs, this article will attempt to provide some basic guidelines that may help junior faculty in diagnostic radiology develop their teaching, research, and service portfolios.

Reader variability in identifying pulmonary nodules on chest radiographs from the national lung screening trial.

Purpose: To measure reader variability related to the evaluation of screening chest radiographs (CXRs) for findings of primary lung cancer. Materials and Methods: From the National Lung Screening Trial (NLST), 100 cases were randomly selected from baseline CXR examinations for retrospective interpretation by 9 NLST radiologists; images with noncalcified lung nodules (NCNs) or other abnormalities suspicious for lung cancer as determined by the original NLST reader were oversampled. Agreement on the presence of pulmonary nodules and abnormalities suspicious for cancer and recommendations for follow-up were assessed by the multirater &kgr; statistic. Results: The multirater &kgr; statistic for interreader agreement on the presence of at least 1 NCN was 0.38. Rates at which readers reported the presence of at least 1 NCN ranged from 32% to 63% (mean, 41%); among 16 subjects with NCN and a cancer diagnosis within 1 year of the CXR examination, an average of 87% (range, 81% to 94%) of cases were classified as suspicious for cancer across all readers. The multirater &kgr; for agreement on follow-up recommendations was 0.34; pairwise &kgr; values ranged from 0.15 to 0.64 (mean, 0.36). For all subjects, readers recommended a follow-up procedure classified as high level (computed tomography, fluorodeoxyglucose-positron emission tomography, or biopsy) 42% of the time on average (range, 30% to 67%); this increased to 84% (range, 52% to 100%) when readers reported an NCN and 88% (range, 82% to 94%) for subjects with cancer. Conclusion: Reader agreement for screening CXR interpretation and follow-up recommendations is fair overall but is high for malignant lesions.

Expected and unexpected imaging features after oesophageal cancer treatment.

Oesophageal cancer is a leading cause of cancer-related mortality worldwide. Various surgical procedures are performed for oesophageal malignancies. The advancement in surgical technique as well as post-surgical care has significantly reduced the complication rate. However, various complications may still occur either immediately (infection, aspiration, anastomotic leak, ischaemic necrosis, fistulae, chylothorax) or late after surgery (strictures, tumour recurrence, fistulae, delayed emptying). The palliative treatment options of radiotherapy and stent placement may also be accompanied by complications, such as radiation necrosis, stricture, and stent ingrowth by the tumour. This review presents the expected post-surgical appearance as well as various complications after surgical and non-surgical treatments of oesophageal cancer.