Integration of endomyocardial biopsy (EMB) in the diagnostic workup of cardiac sarcoidosis (CS) is under-recognized in current clinical practice, since capturing focal granulomas is challenging. Our ...aim was to describe our experience with electro-anatomic mapping (EAM)-guided EMB and provide a comprehensive review of the literature.
Five patients (age 49.4 ± 11.4) with suspected CS underwent EAM-guided EMB in Isala Heart Center (Zwolle, the Netherlands) between 2017 and 2019. In all patients, a 3D bipolar voltage map (<0.5-1.5 mV) and unipolar voltage map (LV < 8.3 mV, RV < 5.5 mV) was created using a high-density mapping catheter. The bioptome was connected to the mapping system to guide targeted EMB. Biopsy samples (2-9 samples) were taken from both LV and RV sites, guided by EAM and areas with abnormal electrograms, without complications. CS diagnosis was based on EMB in 2/5 patients. A granuloma was captured in one patient at the LV basal septum with normal bipolar and abnormal unipolar voltage. All patients with delayed enhancement on cardiac magnetic resonance, revealed fibrosis in the biopsy sample. In one patient with suspected isolated cardiac sarcoidosis, diagnosis could not be confirmed by histopathology analysis, while unipolar voltage mapping was abnormal and diastolic potentials were present. Literature search revealed 7 reports (18 patients) describing EAM-guided EMB in CS patients, with 100% of the EMB taken form the RV.
Unipolar voltage mapping may be superior to target active inflamed tissue and should be evaluated in future research regarding EAM-guided EMB in CS.
Complaints of a dry mouth (xerostomia) and sialoadenitis are frequent side effects of radioiodine treatment in differentiated thyroid cancer (DTC) patients. However, detailed prospective data on ...alterations in salivary gland functioning after radioiodine treatment (
I) are scarce. Therefore, the primary aim of this study was to prospectively assess the effect of high-activity radioiodine treatment on stimulated whole saliva flow rate. Secondary aims were to study unstimulated whole and stimulated glandular (i.e., parotid and submandibular) saliva flow rate and composition alterations, development of xerostomia, characteristics of patients at risk for salivary gland dysfunction, and whether radioiodine uptake in salivary glands on diagnostic scans correlates to flow rate alterations.
In a multicenter prospective study, whole and glandular saliva were collected both before and 5 mo after radioiodine treatment. Furthermore, patients completed the validated xerostomia inventory. Alterations in salivary flow rate, composition, and xerostomia inventory score were analyzed. Salivary gland radioiodine uptake on diagnostic scans was correlated with saliva flow rate changes after radioiodine treatment.
Sixty-seven patients (mean age ± SD, 48 ± 17 y; 63% women, 84% underwent ablation therapy) completed both study visits. Stimulated whole saliva flow rate decreased after ablation therapy (from 0.92 interquartile range, 0.74-1.25 to 0.80 interquartile range, 0.58-1.18 mL/min, P = 0.003), as well as unstimulated whole- and stimulated glandular flow rates (P < 0.05). The concentration of salivary electrolytes was similar at both study visits, whereas the output of proteins, especially amylase (P < 0.05), was decreased. The subjective feeling of dry mouth increased (P = 0.001). Alterations in saliva flow rate were not associated with semiquantitatively assessed radioiodine uptake in salivary glands on diagnostic scans. For the small cohort of patients undergoing repeated radioiodine therapy, we could not demonstrate alterations in salivary parameters.
We prospectively showed that salivary gland function is affected after high-activity radioiodine ablation therapy in patients with DTC. Therefore, more emphasis should be placed on salivary gland dysfunction during follow-up for DTC patients receiving high-activity radioiodine treatment.
During invasive fractional flow reserve (FFR) adenosine and nitrates are used to obtain maximal hyperemia. Severe coronary artery calcification (CAC) is associated with impaired vasodilation. We ...investigated the hyperemic response during FFR in vessels with severe versus mild CAC.
We retrospectively selected 236 patients who underwent both CAC scoring and invasive FFR. FFR was performed in 304 vessels with intermediate stenoses. Delta (Δ) FFR, the pressure gradient before the administration of adenosine minus FFR after the administration of adenosine, was used to investigate the hyperemic response. Mean age of the total population was 65 ± 10 years, 65% was male. Median CAC score was 510 (range 0 to 6141). Mean pressure gradient before the administration of adenosine was comparable in vessels with severe versus mild CAC. FFR was more often ≤0.80 in vessels with severe CAC (p = 0.045). Patients with a large Δ FFR were younger (p = 0.05). There was no association between Δ FFR and severity of calcifications. Regression analysis did not demonstrate an association between CAC score and the hyperemic response (p = 0.49).
We did not find an association between the severity of CAC and the hyperemic response during invasive FFR.
•Coronary artrey calcification (CAC) and invasive fractional flow reserve (FFR) measurements.•304 FFR measurements in vessels with intermediate stenoses.•no association between severity of CAC and hyperemic response.
Patients with ischemic cardiomyopathy (ICM) are at risk for ventricular arrhythmias and are protected by an implantable cardioverter defibrillator (ICD). Visualization of cardiac sympathetic ...innervation may play an additional role to left ventricular ejection fraction (LVEF) in identifying those patients who will benefit from ICD therapy. The purpose of this study was to detect the role of sympathetic denervation in the genesis of ventricular arrhythmias in ICM patients.
Twenty patients with ICM and LVEF <30% were included in this pilot study. Included patients were equally stratified into two groups: no history of arrhythmias (group A) and recurrent arrhythmias (group B). All patients underwent cardiac sympathetic denervation (using carbon-11 labelled meta-hydroxy-ephedrine (11C-mHED)), myocardial ischemia and viability detection. Patients were followed up to one year after the imaging studies.
Mean age was 63±7.5 years. Mean global retention of 11C-mHED was 0.055±0,012 min-1, and was not different between the two patient groups: 0.056±0.011 min-1 vs. 0.054±0.013 min-1 for group A vs. group B, respectively. During follow-up, seven patients developed ventricular arrhythmias, and four patients died. No difference in 11C-mHED retention was found between patients with and without ventricular arrhythmia during follow-up. However, size of denervated area was larger in patients who died during follow-up: 10±1 segments vs. 6±2 segments, P=0.002.
Cardiac sympathetic innervation is impaired in patients with ischemic cardiomyopathy. All-cause mortality occurred in those patients with large areas of 11C-mHED defect.
Ultrasonography (US) can be used for treatment decisions in RA patients. This study investigated the added value of US to clinical variables in predicting flare in RA patients with longstanding low ...disease activity when stopping TNF inhibitors (TNFi).
Cox models with and without using US added to clinical variables were developed in the Potential Optimization of Expediency of TNFi-UltraSonography study. RA patients (n = 259), using >1 year TNFi and csDMARD with DAS28 < 3.2 for 6 months prior to inclusion, were followed for 52 weeks after stopping TNFi. The added value of US was assessed in two ways: first, by the extent to which individual predictions for flare at 52 weeks with and without US differed; and second, by comparing how US information improved the prediction to classify patients at 52 weeks in the low risk (<33% flare), intermediate risk (33-50%) and high risk (50-100%) groups.
Although US was predictive of flare at group level (multivariate hazard ratio = 1.7; 95% CI: 1.1, 2.5), individual predictions for flare at 52 weeks with and without US differed little (median difference 3.7%; interquartile range: -7.8 to 6.5%). With US, 15.9% of patients were designated low risk; without US, 14.6%. In fact, 12.0% of patients were US-classified as low risk with/without knowing US.
In RA patients with longstanding low disease activity, at time of stopping TNFi, US is a predictor for flare at group level, but at the patient level, US has limited added value when common clinical parameters are used already, though the predictive value of clinical predictors is modest as well.
Iterative reconstruction techniques for coronary CT angiography have been introduced as an alternative for traditional filter back projection (FBP) to reduce image noise, allowing improved image ...quality and a potential for dose reduction. However, the impact of iterative reconstruction on the coronary artery calcium score is not fully known. In 112 consecutive stable patients with suspected coronary artery disease, the coronary calcium scores were assessed. Comparisons were made between the Agatston, volume and mass scores obtained with traditional FBP, and by using adaptive statistical iterative reconstruction (ASIR). A significant reduction of the Agatston score, volume score and mass score was observed for ASIR when compared to FBP, with median differences of resp. 26, 5 mm
3
and 1 mg. Using the ASIR reconstruction, the number of patients with a calcium score of zero increased by 13 %. Iterative CT reconstruction significantly reduces the Agatston, volume and mass scores. Since the calcium score is used as a prognostic tool for coronary artery disease, caution must be taken when using iterative reconstruction.
Three commonly used techniques for localization of nonpalpable breast cancer are radioactive seed localization (RSL), wire-guided localization (WGL) and radioguided occult lesion localization (ROLL). ...In this study, we analysed the surgical margins of these three techniques.
Women diagnosed with nonpalpable breast cancer undergoing breast-conserving surgery with one of the above-mentioned techniques were retrospectively included. The primary outcome parameter was tumour-free margin rate. Secondary outcomes were re-excision rate, recurrence of disease and volume of removed tissue.
In total, 272 women were included in whom RSL (n=69), WGL (n=76) or ROLL (n=137) was performed. RSL showed a higher tumour-free margin rate 64 (92.8%) compared with WGL 51 (67.1%) and ROLL 113 (82.5%) (P=0.001). In our multivariable analysis, RSL showed a higher tumour-free margin rate as well compared with WGL (P=0.036) and ROLL (P=0.049). Also, fewer re-excisions were encountered using RSL 5 (7.2%) compared with WGL 13 (17.1%) and ROLL 15 (10.9%) (P=0.171). In 11 patients (WGL n=2, ROLL n=9), recurrence of disease occurred, despite a radical excision. The mean resection volumes were comparable within the three groups.
RSL results in a higher tumour-free margin rate in nonpalpable breast tumours compared with WGL and ROLL. Therefore, we prefer using RSL in nonpalpable breast tumours.
Obtaining optimal pulmonary vein (PV) occlusion with the endoscopic laser balloon ablation system (EAS) can be difficult, hypothetically influenced by PV geometry. The aim of this study was to ...determine the impact of PV orientation on atrial fibrillation (AF)-free survival after PV isolation (PVI) using the EAS.
Forty-three patients undergoing a single EAS PVI were included. Left atrial electrocardiogram -triggered computed tomography was performed in all patients prior to PVI. Of all four PVs, the orientation at the insertion in the left atrium was measured in both the transverse and frontal plane and assigned to one of the four orientation groups: ventral-caudal, dorsal-caudal, ventral-cranial, and dorsal-cranial. Mean age was 56 years; 86% had paroxysmal AF. Overall, AF-free survival after a median follow-up of 18.2 months was 51.2%. AF-free survival varied between 21 and 88% depending on left upper PV orientation (P = 0.045). Furthermore, AF-free survival varied between 21 and 86% depending on left lower PV orientation (P = 0.010) and AF-free survival varied between 29 and 88% depending on right lower PV orientation (P = 0.053). No association was found between right upper PV orientation and AF-free survival after EAS PVI (P = 0.794). In multivariate analysis, only left lower PV orientation was associated with AF-free survival hazards ratio (HR) 10.4, P = 0.019.
PV orientation is associated with AF-free survival after EAS PVI. PV orientation assessment may be useful for selecting the most suitable patients for EAS PVI.
The aim of the study was to investigate the feasibility of (18)F-3'-fluoro-3'-deoxy-L-thymidine positron emission tomography (FLT-PET) for the detection and grading of soft tissue sarcoma (STS).
...Nineteen patients with 20 STSs of the extremities were scanned, using attenuation corrected whole-body FLT-PET. Standardized uptake values (SUVs) and tumor:nontumor ratios (TNTs) were compared with histopathological parameters using French and Japanese grading systems.
Mean SUV, maximal SUV, and TNT could differentiate between low-grade (grade 1; n = 6) STS and high-grade (grade 2 and 3; n = 14) STS according to the French grading system (P = 0.001). Mean SUV, max SUV, and TNT correlated with mitotic score, MIB-1 score, the French and Japanese grading system (* = 0.550-0.747).
FLT-PET is able to visualize STS and differentiate between low-grade and high-grade STS. The uptake of FLT correlates with the proliferation of STS.
Abstract Background Previous studies reported on the impact of pulmonary vein orientation on pulmonary vein isolation (PVI) outcome in atrial fibrillation patients undergoing laser balloon PVI and ...point-by-point radiofrequency ablation. Objective Demonstrate the association between pulmonary vein orientation and PVI outcome after multi-electrode radiofrequency ablation. Methods 120 patients undergoing PVI with a circular MER catheter were included. A left atrial ECG-triggered CT was performed in all patients prior to PVI. The orientation of all pulmonary veins at the insertion into the left atrium was measured in the axial and coronal planes. pulmonary veins were classified as having a ventral/dorsal and caudal/cranial orientation depending on the pulmonary vein trunk angle as compared to the median angle. Results Mean age was 56 years, arrhythmia-free survival after a median follow-up of 20 months was 54.2%. Left upper pulmonary vein orientation within the coronal plane was associated with arrhythmia-free survival, ranging from 58% with a cranial pulmonary vein orientation to 21% with a caudal orientation (p = 0.003). Similarly, arrhythmia-free survival was 50% in patients with a caudal orientation and 33% in patients with a cranial orientation of the left lower pulmonary vein in the coronal plane (p = 0.036). Pulmonary vein orientation in the axial plane and orientation of the right-sided pulmonary veins were not associated with arrhythmia-free survival. Multivariable analysis showed an independent association between both left upper (hazard ratio 2.8, p = 0.001) and left lower (hazard ratio 0.490, p = 0.034) pulmonary vein orientation and arrhythmia-free survival. Conclusion In MER ablation, orientation of the left upper and caudalpulmonary veins in the coronal plane were independently associated with arrhythmia-free survival after multi-electrode PVI.
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