Valerio Alaimo

Coronary artery anomalies: incidence, pathophysiology, clinical relevance and role of diagnostic imaging

Conventional coronary angiography is the gold standard for the diagnosis of coronary artery anomalies. Coronary anomalies are relatively rare findings in patients undergoing conventional coronary angiography for suspected obstructive coronary artery disease. Recently, the increasing performance of diagnostic techniques, such as electron beam tomography (EBT), magnetic resonance (MR) and, more recently, multislice computed tomography (MSCT), has enabled their application to cardiac imaging. MSCT, in particular, has a prominent role in coronary imaging due to its spatial and temporal resolution and threedimensional capabilities. We report the incidence and pathophysiology of coronary artery anomalies based on the capabilities of recent diagnostic tools with the aim of improving an accurate and noninvasive diagnostic approach.

Effect of Observer Experience in the Differentiation Between Benign and Malignant Liver Tumors After Ultrasound Contrast Agent Injection

Objective. The purpose of this study was to assess the impact of the observer level of experience on the diagnostic performance of contrast‐enhanced ultrasound imaging (CEUS) for differentiation between benign and malignant liver tumors. Methods. From a computerized search, we retrospectively identified 286 biopsy‐proven liver tumors (105 hepatocellular carcinomas, 48 metastases, 7 intra‐hepatic cholangiocarcinomas, 33 liver hemangiomas, and 93 nonhemangiomatous benign lesions) in 235 patients (140 male and 95 female; mean age ± SD, 56 ± 11 years) who underwent CEUS after sulfur hexafluoride‐filled microbubble injection. The digital cine clips recorded during the arterial (10–35 seconds from injection), portal (50–120 seconds), and late (130–300 seconds) phases were analyzed by 6 independent observers without experience (group 1, observers 1–3) or with 2 to 10 years of experience in CEUS (group 2, observers 4–6). Specific training in the diagnostic and interpretative criteria was provided to the inexperienced observers. Each observer used a 5‐point scale to grade diagnostic confidence: 1, definitely benign; 2, probably benign; 3, indeterminate; 4, probably malignant; or 5, definitely malignant on the basis of the enhancement pattern during the arterial phase and enhancement degree during the portal and late phases compared with the liver (hypoenhancement indicating malignant and isoenhancement to hyperenhancement indicating benign). Results. The analysis of observer diagnostic confidence revealed higher intragroup (κ = 0.63–0.83) than intergroup (κ = 0.47–0.63) observer agreement. The experienced observers showed higher diagnostic performance in malignancy diagnosis than did inexperienced observers (overall accuracy: group 1, 63.3%–72.8%; group 2, 75.9%–93.1%; P < .05, χ2 test). Conclusions. The diagnostic performance of CEUS in liver tumor characterization was dependant on the observers level of experience.

Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography.

PurposeThis study aimed to assess the prevalence and characteristics of myocardial bridging in patients who underwent multislice computed tomography coronary angiography (MSCT-CA) and to evaluate the correlation between bridged coronary segments and atherosclerosis.Materials and methodsA total of 277 patients (mean age 60±11 years) we consecutively examined with 64-slice MSCT-CA for suspected or known coronary atherosclerosis were retrospectively reviewed for myocardial bridging. Segments proximal and distal to the bridging were evaluated for atherosclerotic plaque, as were the remaining coronary segments.ResultsMyocardial bridging was present in 82 patients (30%, mean age 59±12). Bridges were of variable length (<1 cm 58%; 1-2 cm 32%; >2 cm 10%) and depth (superficial 69%, intramyocardial 31%) and frequently localised in the mid-distal segment of the left anterior descending artery (95%). Myocardial bridging cannot be considered a significant risk factor for coronary atherosclerosis (odds ratio 0.49) compared with traditional cardiovascular risk factors. Coronary segments proximal to the bridge showed no atherosclerotic disease (33%), positive remodelling (27%), <50% stenosis (20%) or >50% stenosis (20%). We identified 12 noncalcified, 32 mixed and 17 calcified plaques. The distal segments were significantly less affected (p<0.0001).ConclusionsMSCT-CA is a reliable, noninvasive method that is able to depict myocardial bridging and associated atherosclerotic plaque in the proximal segments.RiassuntoObiettivoScopo del nostro lavoro è stimare la prevalenza e le caratteristiche dei ponti miocardici in una popolazione consecutiva di pazienti sottoposti ad angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS), nonché valutare la relazione tra i decorsi miocardici e l’aterosclerosi coronarica.Materiali e metodiIn una popolazione di 277 pazienti (età media 60±11), sottoposti consecutivamente ad AC-TCMS con scanner a 64-strati per malattia aterosclerotica coronarica sospetta o nota, è stata ricercata la presenza di decorsi miocardici. Sono state valutate le placche aterosclerotiche presenti nei segmenti prossimali e distali al decorso miocardico, nonché nei restanti segmenti coronarici.RisultatiOttantadue pazienti (30%, età media 59±12) presentano decorso miocardico superficiale (69%) o intramiocardico (31%), con lunghezza variabile (<1 cm: 58%; 1–2 cm: 32%; >2 cm: 10%), frequentemente localizzato nel tratto medio-distale dell’arteria coronaria discendente anteriore (95%). Il ponte miocardico non rappresenta un fattore di rischio significativo di aterosclerosi coronarica (odds ratio 0,49) rispetto ai tradizionali fattori di rischio cardiovascolare. I segmenti prossimali mostrano: assenza di malattia (33%), rimodellamento positivo (27%), stenosi <50% (20%) o >50% (20%). Sono state visualizzate 12 placche non calcifiche, 32 miste e 17 calcifiche. Nei segmenti distali l’aterosclerosi non è rilevante (p<0,0001).ConclusioniLa AC-TCMS è una metodica non invasiva efficace nel dimostrare i ponti miocardici e le placche aterosclerotiche associate presenti nei segmenti prossimali.

Influence of heart rate in the selection of the optimal reconstruction window in routine clinical multislice coronary angiography

PurposeThe aim of our study was to assess the influence of heart rate on the selection of the optimal reconstruction window with 40-slice multidetector-row computed tomography (40-MDCT) coronary angiography.Materials and methodsWe studied 170 patients (114 men, age 60±11.3 years) with suspected or known coronary artery disease with 40-MDCT coronary angiography. Patients [mean heart rate (HR) 62.9±9.3 bpm, range 42–94 bpm] were clustered in two groups (group A: HR ≤65 bpm; group B: HR >65 bpm). Multiphase reconstruction data sets were obtained with a retrospective electrocardiogram (ECG)-gated 40-MDCT coronary angiography scan from 0% to 95% every 5% of the R-R interval. Two radiologists in consensus evaluated the best data sets for diagnostic purposes.ResultsIn group A, the optimal reconstruction windows were at 70% (55/110, 71/110 and 69/110 for the right coronary artery, left anterior descending and the left circumflex, respectively) and 75% (26/110, 28/110 and 28/110, respectively) of the R-R interval. In group B, a wide range of reconstruction windows were employed, both in the end-systolic phase at 40% (32/60, 18/60 and 17/60, for the right coronary artery, left anterior descending and circumflex, respectively) and diastolic phases at 70% (12/60, 22/60 and 19/60, respectively). Six scans were excluded due to severe respiratory artefacts.ConclusionsOptimal position of the image reconstruction window relative to the cardiac cycle is significantly influenced by the heart rate during scanning. Diastolic reconstruction phases often allowed an optimal assessment in group A. Reconstruction phases from 30% to 45% are advisable for higher heart rates.RiassuntoObiettivoScopo del nostro studio è valutare l’influenza della frequenza cardiaca (FC) nella scelta della migliore fase di ricostruzione in angiografia coronarica mediante TC a 40 strati (AC-TCMS).Materiali e metodiCentosettanta pazienti (114 uomini, età 60±11,3 anni) con sospetta o nota malattia coronarica sono stati sottoposti ad AC-TCMS. I pazienti (frequenza media 62,9±9,3 bpm, range 42–94 bpm) sono stati suddivisi in due gruppi (gruppo A: FC≤65 bpm; gruppo B: FC>65 bpm). I dataset multifasici dell’AC-TCMS sono stati ricostruiti ogni 5% da 0% a 95% dell’intero intervallo R-R. Due radiologi hanno valutato in accordo i dataset utilizzabili clinicamente per la refertazione.RisultatiNel gruppo A le fasi di ricostruzione ritenute ottimali sono state il 70% (55/110, 71/110 e 69/110, rispettivamente, per la coronaria destra-CDx-per l’interventricolare anteriore-IVA-e per la circonflessa-CX) ed il 75% (26/110, 28/110 e 28/110, rispettivamente). Nel gruppo B è stata utilizzata un ampia gamma di ricostruzioni, in particolare al 40% (32/60, 18/60 e 17/60, rispettivamente per la CDx, per l’IVA e per la CX) ed al 70% (12/60, 22/60 e 19/60, rispettivamente). Sei esami sono stati esclusi dallo studio per la presenza di artefatti da movimento respiratorio.ConclusioniLa scelta della finestra temporale di ricostruzione è significativamente dipendente dalla FC media durante la scansione. Le ricostruzioni in fase diastolica consentono spesso una valutazione ottimale con FC≤65 bpm. La scelta delle fasi sistoliche (30%–45%) e consigliabile, invece, per FC più elevate.

Prognostic outcome of routine clinical noninvasive multidetector-row computed tomography coronary angiography in patients with suspected coronary artery disease: a 2-year follow-up study

PurposeThe aim of the study was to assess the prognostic value of multidetector-row CT coronary angiography (MDCT-CA) in patients with suspected coronary artery disease (CAD) in a routine clinical context.Materials and methodsA total of 125 patients (82 men, age 57.4±10.3 years) with suspected CAD underwent MDCT-CA. All patients were assessed for cardiovascular risk factors, symptoms and coronary calcium score. A 2-year follow-up study for the occurrence of major adverse cardiac events was performed.ResultsAccording to the Morise pretest score, 76 patients (60.8%) were at intermediate risk. Patients with suspected CAD presented the following prognostic outcome (p<0.0001): in 41 patients with normal coronary arteries at MDCT-CA, the event rate was 0%; five of 49 patients with nonobstructive CAD had major cardiac events; two of 35 patients with obstructive CAD suffered cardiac death and 19 underwent revascularisation. At multivariate analysis, the presence of obstructive CAD is the only significant independent prognostic variable (hazard ratio, 10.1393; 95% confidence interval 3.2189–31.9379; p<0.0001).ConclusionsRoutine clinical MDCT-CA provides an excellent prognostic value at 2-year follow-up in patients with normal coronary arteries. The cardiac event rate increases with CAD severity.RiassuntoObiettivoScopo del nostro lavoro è stato quello di definire il valore prognostico della angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) in pazienti con sospetta malattia aterosclerotica coronarica (MAC) nella routine clinica.Materiali e metodiCentoventicinque pazienti (82 uomini, età media 57,4±10,3 anni) con sospetta MAC sottoposti ad AC-TCMS sono stati inclusi in un follow-up a 2 anni per eventi cardiaci maggiori. È stata effettuata una valutazione dei fattori di rischio, della sintomatologia ed una quantificazione del calcio coronarico.RisultatiSulla base del Morise pre-test score, 76 pazienti (60,8%) presentano rischio intermedio. I pazienti presentano il seguente outcome prognostico (p<0,0001): nessun evento in 41 pazienti con coronarie normali alla AC-TCMS; 5 eventi cardiaci maggiori fra i 49 pazienti con MAC non ostruttiva; 2 morti cardiache e 19 rivascolarizzazioni fra i 35 pazienti con MAC ostruttiva. La presenza di MAC ostruttiva è l’unica variabile prognostica indipendente significativa messa in evidenza dall’analisi multivariata (hazard ratio 10,1393, 95% intervallo di confidenza 3,2189–31,9379, p<0,0001).ConclusioniNella routine clinica la AC-TCMS presenta un eccellente valore prognostico a 2 anni in caso di coronarie normali. Il numero di eventi cardiaci maggiori aumenta con la severità della patologia riscontrata.

Superior Mesenteric Artery Syndrome: Clinical, Endoscopic, and Radiological Findings

Background The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and weight loss. Studies to determine the optimal methods of diagnosis and treatment are required. Aims and Methods This study aims at analyzing the clinical presentation, diagnosis, and management of SMA syndrome. Ten cases of SMA syndrome out of 2074 esophagogastroduodenoscopies were suspected. A contrast-enhanced computed tomography (CECT) scan was performed to confirm the diagnosis. After, a gastroenterologist and a nutritionist personalized the therapy. Furthermore, we compared the demographical, clinical, endoscopic, and radiological parameters of these cases with a control group consisting of 10 cases out of 2380 EGDS of initially suspected (but not radiologically confirmed) SMA over a follow-up 2-year period (2015-2016). Results The prevalence of SMA syndrome was 0.005%. Median age and body mass index were 23.5 years and 21.5 kg/m2, respectively. Symptoms developed between 6 and 24 months. Median aortomesenteric angle and aorta-SMA distance were 22 and 6 mm, respectively. All patients improved on conservative treatment. In our series, a marked (>5 kg) weight loss (p = 0.006) and a long-standing presentation (more than six months in 80% of patients) (p = 0.002) are significantly related to a diagnosis of confirmed SMA syndrome at CECT after an endoscopic suspicion. A “resembling postprandial distress syndrome dyspepsia” presentation may be helpful to the endoscopist in suspecting a latent SMA syndrome (p = 0.02). The narrowing of both the aortomesenteric angle (p = 0.001) and the aortomesenteric distance (p < 0.001) was significantly associated with the diagnosis of SMA after an endoscopic suspicion; however, the narrowing of the aortomesenteric distance seemed to be more accurate, rather than the narrowing of the aortomesenteric angle. Conclusion SMA syndrome represents a diagnostic and therapeutic challenge. Our results show the following findings: the importance of the endoscopic suspicion of SMA syndrome; the preponderance of a long-standing and chronic onset; a female preponderance; the importance of the nutritional counseling for the treatment; no need of surgical intervention; and better diagnostic accuracy of the narrowing of the aorta-SMA distance. Larger prospective studies are needed to clarify the best diagnosis and management of the SMA syndrome.

Valore prognostico nella routine clinica dell'angiografia coronarica non invasiva mediante TC multistrato in pazienti con sospetta malattia coronarica: follow-up a 2 anni

PurposeThe aim of the study was to assess the prognostic value of multidetector-row CT coronary angiography (MDCT-CA) in patients with suspected coronary artery disease (CAD) in a routine clinical context.Materials and methodsA total of 125 patients (82 men, age 57.4±10.3 years) with suspected CAD underwent MDCT-CA. All patients were assessed for cardiovascular risk factors, symptoms and coronary calcium score. A 2-year follow-up study for the occurrence of major adverse cardiac events was performed.ResultsAccording to the Morise pretest score, 76 patients (60.8%) were at intermediate risk. Patients with suspected CAD presented the following prognostic outcome (p<0.0001): in 41 patients with normal coronary arteries at MDCT-CA, the event rate was 0%; five of 49 patients with nonobstructive CAD had major cardiac events; two of 35 patients with obstructive CAD suffered cardiac death and 19 underwent revascularisation. At multivariate analysis, the presence of obstructive CAD is the only significant independent prognostic variable (hazard ratio, 10.1393; 95% confidence interval 3.2189–31.9379; p<0.0001).ConclusionsRoutine clinical MDCT-CA provides an excellent prognostic value at 2-year follow-up in patients with normal coronary arteries. The cardiac event rate increases with CAD severity.RiassuntoObiettivoScopo del nostro lavoro è stato quello di definire il valore prognostico della angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) in pazienti con sospetta malattia aterosclerotica coronarica (MAC) nella routine clinica.Materiali e metodiCentoventicinque pazienti (82 uomini, età media 57,4±10,3 anni) con sospetta MAC sottoposti ad AC-TCMS sono stati inclusi in un follow-up a 2 anni per eventi cardiaci maggiori. È stata effettuata una valutazione dei fattori di rischio, della sintomatologia ed una quantificazione del calcio coronarico.RisultatiSulla base del Morise pre-test score, 76 pazienti (60,8%) presentano rischio intermedio. I pazienti presentano il seguente outcome prognostico (p<0,0001): nessun evento in 41 pazienti con coronarie normali alla AC-TCMS; 5 eventi cardiaci maggiori fra i 49 pazienti con MAC non ostruttiva; 2 morti cardiache e 19 rivascolarizzazioni fra i 35 pazienti con MAC ostruttiva. La presenza di MAC ostruttiva è l’unica variabile prognostica indipendente significativa messa in evidenza dall’analisi multivariata (hazard ratio 10,1393, 95% intervallo di confidenza 3,2189–31,9379, p<0,0001).ConclusioniNella routine clinica la AC-TCMS presenta un eccellente valore prognostico a 2 anni in caso di coronarie normali. Il numero di eventi cardiaci maggiori aumenta con la severità della patologia riscontrata.

Prognostic outcome of routine clinical noninvasive multidetector-row computed tomography coronary angiography in patients with suspected coronary artery disease: a 2-year follow-up study@@@Valore prognostico nella routine clinica dell’angiografia coronarica non invasiva mediante TC multistrato in pazienti con sospetta malattia coronarica: follow-up a 2 anni

PurposeThe aim of the study was to assess the prognostic value of multidetector-row CT coronary angiography (MDCT-CA) in patients with suspected coronary artery disease (CAD) in a routine clinical context.Materials and methodsA total of 125 patients (82 men, age 57.4±10.3 years) with suspected CAD underwent MDCT-CA. All patients were assessed for cardiovascular risk factors, symptoms and coronary calcium score. A 2-year follow-up study for the occurrence of major adverse cardiac events was performed.ResultsAccording to the Morise pretest score, 76 patients (60.8%) were at intermediate risk. Patients with suspected CAD presented the following prognostic outcome (p<0.0001): in 41 patients with normal coronary arteries at MDCT-CA, the event rate was 0%; five of 49 patients with nonobstructive CAD had major cardiac events; two of 35 patients with obstructive CAD suffered cardiac death and 19 underwent revascularisation. At multivariate analysis, the presence of obstructive CAD is the only significant independent prognostic variable (hazard ratio, 10.1393; 95% confidence interval 3.2189–31.9379; p<0.0001).ConclusionsRoutine clinical MDCT-CA provides an excellent prognostic value at 2-year follow-up in patients with normal coronary arteries. The cardiac event rate increases with CAD severity.RiassuntoObiettivoScopo del nostro lavoro è stato quello di definire il valore prognostico della angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) in pazienti con sospetta malattia aterosclerotica coronarica (MAC) nella routine clinica.Materiali e metodiCentoventicinque pazienti (82 uomini, età media 57,4±10,3 anni) con sospetta MAC sottoposti ad AC-TCMS sono stati inclusi in un follow-up a 2 anni per eventi cardiaci maggiori. È stata effettuata una valutazione dei fattori di rischio, della sintomatologia ed una quantificazione del calcio coronarico.RisultatiSulla base del Morise pre-test score, 76 pazienti (60,8%) presentano rischio intermedio. I pazienti presentano il seguente outcome prognostico (p<0,0001): nessun evento in 41 pazienti con coronarie normali alla AC-TCMS; 5 eventi cardiaci maggiori fra i 49 pazienti con MAC non ostruttiva; 2 morti cardiache e 19 rivascolarizzazioni fra i 35 pazienti con MAC ostruttiva. La presenza di MAC ostruttiva è l’unica variabile prognostica indipendente significativa messa in evidenza dall’analisi multivariata (hazard ratio 10,1393, 95% intervallo di confidenza 3,2189–31,9379, p<0,0001).ConclusioniNella routine clinica la AC-TCMS presenta un eccellente valore prognostico a 2 anni in caso di coronarie normali. Il numero di eventi cardiaci maggiori aumenta con la severità della patologia riscontrata.