Vibhav Rangarajan

AJM onlineImages in radiologyResistant Hypertension

DIAGNOSIS Three-dimensional contrast-enhanced magnetic resonance angiography showed significant focal aortic coarctation, just beyond the origin of the left subclavian artery (Figure 1 and Online Video 1). Coarctation is a vascular disease with narrowing of the aorta and is a common congenital malformation, accounting for up to approximately 1 in 2500 live births. It can be classified anatomically on the basis of its location relative to the fetal ductus arteriousus as preductal, juxtaductal, or postductal. The postductal and juxtaductal types are the most common forms seen in adults. The majority of patients (50%-85%) have associated bicuspid aortic valve disease, as in this case (Figure 2 and Online Video 2) with an associated aortic ejection click on physical examination.

Overall impact of outpatient stress cardiac magnetic resonance (CMR) imaging on clinical care is independent of appropriate use criteria

Background Stress cardiac-magnetic-resonance (CMR) imaging can provide important diagnostic and prognostic information in patients with known or suspected coronary artery disease. However, given the rising costs of imaging, there is increasing pressure to provide evidence for direct additive impact on clinical care. Appropriate use criteria (AUC) have been developed by professional organizations as a response to rising costs, with the goal of optimizing test-patient selection. Consequently, the AUC are now increasingly used by third-party-payers to assess reimbursement. However, these criteria were created by expert consensus with limited systematic validation. The aim of this study was to determine whether the AUC can predict rates of active change in clinical care resulting from stress CMR.

Longitudinal fiber dysfunction assessed during cine-cardiac magnetic resonance imaging is an independent predictor of adverse cardiac events

Background Left ventricular systole involves coordinated contraction of longitudinal, circumferential, and radial myocardial fibers. Longitudinal fiber dysfunction appears to be an early marker for a number of pathological states. We hypothesized that reduced mitral annular plane systolic excursion (MAPSE) measured during cine-Cardiac Magnetic Resonance (CMR) imaging reflects changes in longitudinal fiber function and may be an early marker for adverse cardiovascular outcomes.

A continuous murmur

Continuous murmurs are those that begin in systole and continue without interruption through the second heart sound, even if they do not occupy all of diastole. Important pathological causes in adults include patent ductus arteriosus, ruptured sinus of valsalva, aortic coarctation, branch pulmonary stenosis, and coronary or peripheral arteriovenous fistula. ### Case A previously well 57-year-old-woman presented with several months of exertional dyspnoea and occasional irregular palpitations. Physical examination was notable for symmetrical pulses with a wide pulse pressure (BP=160/50), a displaced apical impulse, and a continuous murmur loudest in the second left intercostal space. Cardiac MRI demonstrated a patent ductus arteriosus connecting the proximal left pulmonary artery to the descending aorta, distal to the left subclavian artery (figure 1A, B, arrows and see online supplementary video …

Appropriate use criteria and the impact of stress cardiovascular magnetic resonance (CMR) imaging on management of patients with known or suspected coronary artery disease

Background Stress-CMR provides important diagnostic and prognostic information in patients with known or suspected coronary artery disease. However, in the current fiscal environment, use of a newer imaging modality like stress-CMR requires evidence for direct additive impact on clinical management. Appropriate use criteria (AUC) have recently been developed to provide guidance to physicians and payers regarding the appropriateness of this test in various clinical scenarios. However, these criteria were created by expert consensus and have never been systematically validated. The aims of this study were 1) to evaluate the impact of stress-CMR on clinical management; and 2) to determine the relationship of the AUC with active clinical impact.

Paradoxical embolism in Ebstein's anomaly

A 30-year-old woman presented with sudden onset left flank pain 10 days following an uncomplicated delivery. She was normotensive with an electrocardiogram showing sinus-rhythm and pre-excitation ( Panel A ). Abdominal-computed tomography revealed a large wedge-shaped infarct in the left kidney ( Panel B , arrows). Lower-extremity doppler-imaging showed small bilateral deep-vein thromboses and anti-coagulation was initiated. Echocardiography suggested apical displacement of the …