Abstract Objective(s) Localization and resection of non-visible, non-palpable pulmonary nodules during video-assisted thoracoscopic surgery (VATS) is challenging. Our study was to determine the ...feasibility and safety of indocyanine green (ICG) fluorescence localization and resection of small nodules using a near-infrared (NIR) fluorescence thoracoscope. Methods Twenty patients with undiagnosed peripheral nodules smaller than 3cm scheduled for CT-guided microcoil placement followed by VATS wedge resection were enrolled. After microcoil deployment, 100-150 μl of diluted ICG was injected percutaneously near the nodule. The nodule was initially localized solely by using the NIR thoracoscope to visualize ICG fluorescence. Thoracoscopic instruments were used to determine the staple line. Wedge resection was performed after confirmation of the location of the microcoil using fluoroscopy. Results Twenty patients underwent NIR image-guided VATS resection. The median CT tumor size was 1.2 cm. The median depth from the pleural surface was 1.4 cm (range: 0.2-4.8). The median CT-guided intervention time was 35 min and VATS procedural time was 54 min. ICG fluorescence was clearly identified in 18 of 20 cases (90%). The surgical margins were all negative on final pathology without the need of additional resection. The final diagnoses included 18 primary lung cancer, 1 metastatic lung cancer, and 1 benign lung tumor. Conclusions CT-guided percutaneous ICG injection and intraoperative NIR localization of small nodules is safe and feasible. It offers surgeons the ease of localization through direct ICG fluorescence imaging without the use of fluoroscopy and may be a complementary technique to preoperative microcoil placement for non-visible, non-palpable intrapulmonary nodules.
Abstract Background Angina is a frequent symptom in patients with hypertrophic cardiomyopathy (HCM); however, it is often not because of significant epicardial coronary artery stenosis. Coronary CT ...angiography (CCTA) is an excellent modality to rule out significant coronary artery stenosis in the low- and intermediate-risk patients; however, its value in patients with HCM has not been explored. We sought to assess the utility of CCTA in the assessment of patients with HCM and stable anginal symptoms and compare the incidence of epicardial coronary artery stenosis to an age- and gender-matched control group. Methods Consecutive outpatients with HCM referred for CCTA over a 3-year period because of stable anginal symptoms (chest pain or shortness of breath) were identified retrospectively. Age- and gender-matched patients without HCM referred for CCTA because of similar symptoms over a 6-month period were used as controls. All patients had CCTA using an Aquilion ONE 320 scanner. The coronary arteries were evaluated independently by 2 blinded observers, and any luminal narrowing was scored quantitatively as follows: >70% = severe; 50% to 70% = moderate; <50% = mild; and none. For the HCM group, results of cardiac single-photon emission CT (SPECT) or cardiac magnetic resonance perfusion studies as well as catheter angiograms were recorded where available. Results A total of 91 patients with HCM and 91 controls were included. No significant difference in cardiac risk factors was present between the 2 groups. The CCTA was of diagnostic quality in all patients. The median (interquartile range) calcium score was lower in patients with HCM (0 0–50 vs 2 0–189) but did not reach statistical significance ( P = .23). The incidence of moderate-to-severe coronary artery stenosis was significantly lower in patients with HCM than in controls (6.6% vs 33.0%; P < .001). The incidence of left anterior descending artery luminal narrowing overall was also significantly lower in the HCM patients (7.0% vs 20.9%; P = .002). There was a higher incidence of myocardial bridging in patients with HCM (40.7% vs 6.6%; P < .001), with longer and deeper bridged segments. Among a subgroup of HCM patients (n = 24) who had either stress perfusion CMR or cardiac single-photon emission CT studies performed, 15 of 24 had false-positive perfusion abnormalities without evidence of luminal obstruction on CCTA. Conclusion We demonstrate the use of CCTA for the assessment of stable anginal symptoms in patients with HCM. The incidence of moderate-to-severe coronary artery stenosis was significantly lower in our HCM patients in comparison to our age-matched, gender-matched, and risk factor–matched control group. Given the high incidence of false-positive findings on perfusion stress studies, we propose that CCTA may be useful for appropriate triage to coronary angiography in the HCM patient with anginal symptoms.
Abstract Objective The left ventricle (LV) is routinely assessed with cardiac magnetic resonance imaging (MRI) by using short-axis orientation; it remains unclear whether the right ventricle (RV) can ...also be adequately assessed in this orientation or whether dedicated axial orientation is required. We used phase-contrast (PC) flow measurements in the main pulmonary artery (MPA) and the ascending aorta (Aorta) as nonvolumetric standard of reference and compared RV and LV volumes in short-axis and axial orientations. Methods A retrospective analysis identified 30 patients with cardiac MRI data sets. Patients underwent MRI (1.5 T or 3 T), with retrospectively gated cine steady-state free-precession in axial and short-axis orientations. PC flow analyses of MPA and Aorta were used as the reference measure of RV and LV output. Results There was a high linear correlation between MPA-PC flow and RV–stroke volume (SV) short axis ( r = 0.9) and RV-SV axial ( r = 0.9). Bland-Altman analysis revealed a mean offset of 1.4 mL for RV axial and –2.3 mL for RV–short-axis vs MPA-PC flow. There was a high linear correlation between Aorta-PC flow and LV-SV short-axis ( r = 0.9) and LV-SV axial ( r = 0.9). Bland-Altman analysis revealed a mean offset of 4.8 m for LV short axis and 7.0 mL for LV axial vs Aorta-PC flow. There was no significant difference ( P = .6) between short-axis–LV SV and short-axis–RV SV. Conclusion No significant impact of the slice acquisition orientation for determination of RV and LV stroke volumes was found. Therefore, cardiac magnetic resonance workflow does not need to be extended by an axial data set for patients without complex cardiac disease for assessment of biventricular function and volumes.
No published studies have evaluated the role of cardiac magnetic resonance (CMR) imaging for the assessment of Ebstein anomaly. Our objective was to evaluate the right heart characteristics in adults ...with unrepaired Ebstein anomaly using contemporary CMR imaging techniques. Consecutive patients with unrepaired Ebstein anomaly and complete CMR studies from 2004 to 2009 were identified (n = 32). Volumetric measurements were obtained from the short-axis and axial views, including assessment of the functional right ventricular (RV) end-diastolic volume (EDV) and end-systolic volume. The volume of the atrialized portion of the right ventricle in end-diastole was calculated as the difference between the total RVEDV and the functional RVEDV. The reproducibility of the measurements in the axial and short-axis views was determined within and between observers. The median value derived from the short-axis and axial views was 136 ml/m2 (range 59 to 347) and 136 ml/m2 (range 63 to 342) for the functional RVEDV, 153 ml/m2 (range 64 to 441) and 154 ml/m2 (range 67 to 436) for the total RVEDV, 49% (range 32% to 46%) and 50% (range 40% to 64%) for the functional RV ejection fraction, respectively. The axial measurements demonstrated lower intraobserver and interobserver variability than the short-axis approach for all values, with the exception of the intraobserver functional RVEDV and interobserver total RVEDV for which the limits of agreement and variance were not significantly different between the 2 views. In conclusion, measurements of right heart size and systolic function in patients with Ebstein anomaly can be reliably achieved using CMR imaging. Axial imaging appeared to provide more reproducible data than that obtained from the short-axis views.
This is a cardiothoracic curriculum document for radiology residents meant to serve not only as a study guide for radiology residents but also as a teaching and curriculum reference for radiology ...educators and radiology residency program directors. This document represents a revision of a cardiothoracic radiology resident curriculum that was published 10 years ago in Academic Radiology. The sections that have been significantly revised, expanded, or added are (1) lung cancer screening, (2) lung cancer genomic profiling, (3) lung adenocarcinoma revised nomenclature, (4) lung biopsy technique, (5) nonvascular thoracic magnetic resonance, (6) updates to the idiopathic interstitial pneumonias, (7) cardiac computed tomography updates, (8) cardiac magnetic resonance updates, and (9) new and emerging techniques in cardiothoracic imaging. This curriculum was written and endorsed by the Education Committee of the Society of Thoracic Radiology. This curriculum operates in conjunction with the Accreditation Council for Graduate Medical Education (ACGME) milestones project that serves as a framework for semiannual evaluation of resident physicians as they progress through their training in an ACGME-accredited residency or fellowship programs. This cardiothoracic curriculum document is meant to serve not only as a more detailed guide for radiology trainees, educators, and program directors but also complementary to and guided by the ACGME milestones.
Abstract Computed tomography and magnetic resonance imaging features of inflammatory intracardiac and pulmonary masses secondary to Behcet disease have not been well described in the literature. We ...present a case of Behcet disease, presenting with enhancing cardiac and pulmonary inflammatory masses that mimicked the imaging appearance of metastatic cardiac angiosarcoma. Subsequent magnetic resonance imaging examination showed the mass reduced in size with immunosuppressive therapy. This case highlights the importance of considering Behcet disease in the differential diagnosis for an enhancing cardiac mass.
Abstract Background The diagnosis of pericardial constriction remains challenging. Purpose We sought to evaluate the predictive value of cardiovascular CT-based measurements of inferior vena cava ...(IVC) parameters in the diagnosis of pericardial constriction. Methods Forty-two consecutive patients referred for assessment of pericardial constriction by 64-slice CT were evaluated. The diagnosis of pericardial constriction was confirmed by clinical history, echocardiography, cardiac catheterization, intraoperative findings, histopathology, or a combination. Diameter and cross-sectional area of the suprahepatic IVC and cross-sectional area of the aorta were measured on a single-axial CT image at the level of the esophageal hiatus. Maximum pericardial thickness was measured. Logistic regression and receiver operating curve analyses were performed. Results Twenty-two patients had pericardial constriction. Mean age of the 42 patients was 57.1 ± 16.4 years, 57.1% were men. IVC diameter, IVC area, the ratio of IVC to aortic area, and pericardial thickness were all significantly greater in patients with constriction than in patients without ( P < .05 for all). IVC-to-aortic area ratio had the highest odds ratio (51; 95% CI, 2.8–922) for the prediction of constriction and remained a significant predictor in multivariable analysis. In nested models, IVC-to-aortic area ratio had incremental value over pericardial thickness for the diagnosis of constriction. IVC-to-aortic area ratio discriminated between patients with and without constriction with an area under the curve of 0.88 on receiver operating curve analysis, with a value ≥1.6 having a sensitivity and specificity of 95% and 76%, respectively. Interobserver agreement for IVC-to-aortic area ratio was excellent (intraclass correlation coefficient, 0.98). Conclusion Assessment of IVC-to-aortic area ratio on CT aids with the diagnosis of pericardial constriction and has independent and incremental value over pericardial thickness alone.
Abstract Purpose To evaluate the value of cardiac magnetic resonance imaging (MRI)–based measurements of inferior vena cava (IVC) cross-sectional area in the diagnosis of pericardial constriction. ...Methods Patients who had undergone cardiac MRI for evaluation of clinically suspected pericardial constriction were identified retrospectively. The diagnosis of pericardial constriction was established by clinical history, echocardiography, cardiac catheterization, intraoperative findings, and/or histopathology. Cross-sectional areas of the suprahepatic IVC and descending aorta were measured on a single axial steady-state free-precession (SSFP) image at the level of the esophageal hiatus in end-systole. Logistic regression and receiver-operating curve (ROC) analyses were performed. Results Thirty-six patients were included; 50% (n = 18) had pericardial constriction. Mean age was 53.9 ± 15.3 years, and 72% (n = 26) were male. IVC area, ratio of IVC to aortic area, pericardial thickness, and presence of respirophasic septal shift were all significantly different between patients with constriction and those without ( P < .001 for all). IVC to aortic area ratio had the highest odds ratio for the prediction of constriction (1070, 95% confidence interval 8.0-143051, P = .005). ROC analysis illustrated that IVC to aortic area ratio discriminated between those with and without constriction with an area under the curve of 0.96 (95% confidence interval 0.91-1.00). Conclusions In patients referred for cardiac MRI assessment of suspected pericardial constriction, measurement of suprahepatic IVC cross-sectional area may be useful in confirming the diagnosis of constriction when used in combination with other imaging findings, including pericardial thickness and respirophasic septal shift.
Background Conventional coronary angiography (CCA) may be inaccurate to distinguish between interarterial and septal subtypes of anomalous left coronary arteries (CAs). Objective We compared the ...classification of anomalous left CA arising from the right sinus of Valsalva (RSV) or right CA on the basis of multidetector computed tomography coronary angiography (MDCTCA) with the classification derived from CCA. Methods A retrospective review of 6000 consecutive electrocardiographic-gated MDCTCAs identified 15 cases of anomalous left main or left anterior descending CA arising from the RSV or right CA coursing between the aorta and the main pulmonary artery. On the basis of MDCTCA findings, the proximal course of each vessel was classified into 3 subtypes: 1, interarterial; 2, septal; and 3, mixed. CCA was reviewed in 5 cases (33%) and classified according to traditional criteria. When CCA images were not available, 3-dimensional volume-rendered reconstructions were used to simulate CCA. Results On the basis of MDCTCA, subtypes were distributed as type 1 (n = 2), type 2 (n = 4), and type 3 (n = 8). One case could not be classified into any of these subtypes and was classified as type 4, right ventricular infundibulum (RVI). Applying CCA criteria, 2 cases would have been classified as interarterial and 14 as septal without appreciation of the mixed or RVI subtypes. Conclusions Classification of anomalous left CAs into either septal or interarterial may be too simplistic. There is an anatomic spectrum of anomalous left CAs detected by MDCTCA that challenges the traditional classification based on CCA.
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