Silvana Mueller

Multislice Computed Tomography in Infective Endocarditis Comparison With Transesophageal Echocardiography and Intraoperative Findings

OBJECTIVES The aim of this study was to assess the value of multislice computed tomography (CT) for the assessment of valvular abnormalities in patients with infective endocarditis (IE) in comparison with transesophageal echocardiography (TEE) and intraoperative findings. BACKGROUND Multislice CT has recently shown promising data regarding valvular imaging in a 4-dimensional fashion. METHODS Thirty-seven consecutive patients with clinically suspected IE were examined with TEE and 64-slice CT or dual-source CT. Twenty-nine patients had definite IE and underwent surgery. RESULTS The diagnostic performance of CT for the detection of evident valvular abnormalities for IE compared with TEE was: sensitivity 97%, specificity 88%, positive predictive value (PPV) 97%, and negative predictive value (NPV) 88% on a per-patient basis (n = 37; excellent intermodality agreement kappa = 0.84). CT correctly identified 26 of 27 (96%) patients with valvular vegetations and 9 of 9 (100%) patients with abscesses/pseudoaneurysms compared with the intraoperative specimen. On a per-valve-based analysis, diagnostic accuracy for the detection of vegetations and abscesses/pseudoaneurysms compared with surgery was: sensitivity 96%, specificity 97%, PPV 96%, NPV 97%, and sensitivity 100%, specificity 100%, PPV 100%, NPV 100%, respectively, without significant differences as compared with TEE. Vegetation size measurements by CT correlated (r = 0.95; p <0.001) with TEE (mean 7.6 +/- 5.6 mm). The mobility of vegetations was accurately diagnosed in 21 of 22 (96%) patients with CT, but all of 4 leaflet perforations (<or=2 mm) were missed. CT provided more accurate anatomic information regarding perivalvular extent of abscess/pseudoaneurysms than TEE. CONCLUSIONS Multislice CT shows good results in detecting valvular abnormalities in IE and could be applied in pre-operative planning and exclusion of coronary artery disease before surgery.

Benefits of High-Pitch 128-Slice Dual-Source Computed Tomography for Planning of Transcatheter Aortic Valve Implantation

BACKGROUND Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for high-risk and inoperable patients. Advanced multimodality imaging, including computed tomography (CT), plays a key role for optimized planning of TAVI. METHODS Forty-nine patients (25 women; age, 82.3±8.8 year) with severe aortic stenosis scheduled for TAVI were examined with 128-slice high-pitch dual-source prospective aortoiliac CT angiography (CTA). The 3-coronary-sinus-alignment (3-CSA) plane, comprising left and right anterior oblique and craniocaudal projection, was defined from three-dimensional volume-rendered technique data sets and compared with the intraoperative angiographic plane (deployment plane) used for device implantation. A tolerance level of ±5-degree deviation was acceptable. Volume of intraoperative iodine contrast agent was compared before and after the implementation of the 3-CSA plane estimation by CT. RESULTS All 49 patients underwent TAVI, during which 6 CoreValves (Medtronic, Minneapolis, MN) and 43 Sapien valves (Edwards Lifesciences, Irvine, CA) were successfully implanted using transapical (n=29), transfemoral (n=17), and transaxillary access (n=4). No severe complications occurred. In 47 patients (96%), CTA correctly predicted the 3-CSA plane used for device implantation. Mean left anterior oblique by CTA was 5.3±6.5 degrees and craniocaudal was -1.3±10.1 degrees. Mean left anterior oblique deviation between CTA and the intraoperative projection was 2.1±2.7 degrees and craniocaudal was 1.7±3.0 degrees. Ostium heights of the right and left coronary arteries were 12±1.9 and 12.9±3.3 mm. No over-stenting occurred in left coronary artery ostia of 8 mm or more. Contrast volume was reduced from 81.8±25.6 to 59.4±40.2 mL (p=0.05) when using 3-CSA plane estimation by CT for final prosthesis implantation plane. CONCLUSIONS Aortoiliac high-pitch 128-slice dual-source CT contributes to TAVI planning, including reliable prediction of the 3-CSA valve deployment plane, which saves contrast volume during the procedure and may facilitate correct valve placement.

Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography.

RATIONALE AND OBJECTIVES Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.

Original investigationQuantification of Aortic Regurgitant Fraction and Volume with Multi-detector Computed Tomography: Comparison with Echocardiography

RATIONALE AND OBJECTIVES Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.

Experience on the Way to Totally Endoscopic Atrial Septal Defect Repair

BACKGROUND Remote-access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect (ASD) and patent foramen ovale (PFO). We report on a stepwise approach to a totally endoscopic procedure. METHODS Seventeen patients (median age, 39 years; range, 21-55 years) underwent limited-access ASD or PFO closure. As a preparative step, the operation was carried out through minithoracotomy in 11 patients. In parallel, experience with robotic surgery was gained with totally endoscopic coronary artery bypass grafting procedures. After performance of ASD closures in dry-laboratory models using the da Vinci telemanipulation system, 6 patients were operated on in a totally endoscopic fashion. RESULTS With the endoscopic approach, significant learning curves were noted for cardiopulmonary bypass time y(min) = 226 - 41 * ln(x) (P = .03) and aortic cross-clamp time y(min) = 134 - 42 * ln(x) (P = .01) (x = number of procedures). There was no hospital mortality, and no residual shunts were detected at postoperative echocardiography. Median ventilation time was 9 hours (range, 0-18 hours) for the minithoracotomy group and 6 hours (range, 4-19 hours) for the totally endoscopic group. Median intensive care unit stay was 20 hours (range, 18-24 hours) and 18 hours (range, 18- 120 hours), respectively. CONCLUSIONS The implementation of robotic totally endoscopic closure of ASD or PFO in a heart surgery program seems to be safe. An intermediate step of performing the operations through minithoracotomy, adapting to remote access perfusion systems, and gaining experience in other robotic cardiac surgical procedures seems worthwhile. Learning curves are apparent, and adequate defect closure does not seem to be compromised by the totally endoscopic approach.

Detection of bioprosthetic valve infection by image fusion of (18)fluorodeoxyglucose-positron emission tomography and computed tomography.

A 63-year old male with prior bioprosthetic mitral valve replacement and coronary artery bypass graft surgery presented with dyspnea. C-reactive protein and white blood cells were elevated and serial blood cultures were negative. Transesophageal echocardiography showed a paravalvular leak and a thickened anterior leaflet of unclear either infective or degenerative origin. For differential diagnosis, cardiac 128-dual source computed tomography (CT) was performed. The CT image showed a thickened anterior leaflet and further revealed that the paravalvular leak was draining into a large wall thickened pseudoaneurysm with dense tissue adjacent suggestive for an abscess. Therefore, (18)fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) was appended and fused with the CT images. There was no tracer-uptake surrounding the leak excluding an abscess. However, an increased (18)FDG-tracer uptake at the thickened anterior leaflet indicated active inflammation. During the subsequent cardiac surgery, vegetations were identified on the anterior cusp of the bioprosthetic valve. Intraoperative biopsy was taken and the cell culture was positive for Staphylococcus aureus. The pseudoaneurysm was repaired and the valve was replaced with a bioprosthesis. The patient was discharged uneventfully from hospital on day 12 and antibiotic treatment was continued for 4 weeks. In conclusion, our case indicates that (18)FDG-PET with cardiac CT image fusion may be a useful tool in patients with unclear focus of inflammation and possible bioprosthesis infection.

Paravalvular prosthetic valve abscess detected with 18FDG-PET/128-slice CT image fusion

A 74-year-old male with a mechanic aortic valve prosthesis presented with a transient ischaemic attack. The c-reactive protein level was slightly above normal with 1.09, 1.39, and 1.08 mg/dL monitored over 3 days. White blood count was normal. Two serial blood cultures were negative. d-dimer was elevated (1.101 µg/L). Transoesophageal echocardiography (TEE) showed a paravalvular leak ( Figure 1 , Supplementary data online, Movie S1–S2 ), and an …

Prolapsing Atrial Myxoma Dynamic Visualization With Multislice Computed Tomography

An 80-year-old woman had a history of increasing dyspnea with a sensation of thoracic pressure. Transthoracic echocardiography demonstrated a mobile hyperechoic mass located in the left atrium (Figure 1A) and prolapsing into the left ventricle (Figure 2A). A moderate obstruction of the mitral valve was observed. The mass was suspicious for a cardiac tumor, although an additional thrombus formation could not be excluded. Accordingly, a contrast-enhanced, ECG-gated, 16-row helical CT scan (Sensation 16, Siemens) demonstrated a hypodense mass based on …An 80-year-old woman had a history of increasing dyspnea with a sensation of thoracic pressure. Transthoracic echocardiography demonstrated a mobile hyperechoic mass located in the left atrium (Figure 1A) and prolapsing into the left ventricle (Figure 2A). A moderate obstruction of the mitral valve was observed. The mass was suspicious for a cardiac tumor, although an additional thrombus formation could not be excluded. Accordingly, a contrast-enhanced, ECG-gated, 16-row helical CT scan (Sensation 16, Siemens) demonstrated a hypodense mass based on …

Cardiac CTA for Evaluation of Prosthetic Valve Dysfunction

The objective of the study was to evaluate the accuracy of cardiac computed tomography angiography (CTA) for the diagnosis of prosthetic valve dysfunction (PVD) compared with surgery. Patients after heart valve repair who were referred for clinically indicated CTA (coronary artery or bypass graft

TCT-110 Lower risk of severe acute kidney injury in transcatheter aortic valve replacement: intracardiac echocardiography lowers radiocontrast medium requirements

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