Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement

Recent years have witnessed exponential growth in cardiac imaging technologies, allowing better visualization of complex cardiac anatomy and improved assessment of physiology. These advances have become increasingly important as more complex surgical and catheter-based procedures are evolving to address the needs of a growing congenital heart disease population. This state-of-the-art review presents advances in echocardiography, cardiac magnetic resonance, cardiac computed tomography, invasive angiography, 3-dimensional modeling, and digital twin technology. The paper also highlights the integration of artificial intelligence with imaging technology. While some techniques are in their infancy and need further refinement, others have found their way into clinical workflow at well-resourced centers. Studies to evaluate the clinical value and cost-effectiveness of these techniques are needed. For techniques that enhance the value of care for congenital heart disease patients, resources will need to be allocated for education and training to promote widespread implementation.

Technical recommendations for computed tomography guidance of intervention in the right ventricular outflow tract: Native RVOT, conduits and bioprosthetic valves:: A white paper of the Society of Cardiovascular Computed Tomography (SCCT), Congenital Heart Surgeons' Society (CHSS), and Society for Cardiovascular Angiography & Interventions (SCAI)

This consensus document for the performance of Cardiovascular Computed Tomography (CCT) to guide intervention in the right ventricular outflow tract (RVOT) in patients with congenital disease (CHD) was developed collaboratively by pediatric and adult interventionalists, surgeons and cardiac imagers with expertise specific to this patient subset. The document summarizes definitions of RVOT dysfunction as assessed by multi-modality imaging techniques and reviews existing consensus statements and guideline documents pertaining to indications for intervention. In the context of this background information, recommendations for CCT scan acquisition and a standardized approach for reporting prior to surgical or transcatheter pulmonary valve replacement are proposed and presented. It is the first Imaging for Intervention collaboration for CHD patients and encompasses imaging and reporting recommendations prior to both surgical and percutaneous pulmonary valve replacement.

Left Ventricular Outflow Tract Obstruction in Congenital Heart Disease: The Role of Cardiovascular Computed Tomography in Surgical Decision Making

Patients with many forms of congenital heart disease (CHD) and hypertrophic cardiomyopathy undergo surgical intervention to relieve left ventricular outflow tract obstruction (LVOTO). Cardiovascular Computed Tomography (CCT) defines the complex pathway from the ventricle to the outflow tract and can be visualized in 2D, 3D, and 4D (3D in motion) to help define the mechanism and physiologic significance of obstruction. Advanced cardiac visualization may aid in surgical planning to relieve obstruction in the left ventricular outflow tract, aortic or neo-aortic valve and the supravalvular space. CCT scanner technology has advanced to achieve submillimeter, isotropic spatial resolution, temporal resolution as low as 66 msec allowing high-resolution imaging even at the fast heart rates and small cardiac structures of pediatric patients ECG gating techniques allow radiation exposure to be targeted to a minimal portion of the cardiac cycle for anatomic imaging, and pulse modulation allows cine imaging with a fraction of radiation given during most of the cardiac cycle, thus reducing radiation dose. Scanning is performed in a single heartbeat or breath hold, minimizing the need for anesthesia or sedation, for which CHD patents are highest risk for an adverse event. Examples of visualization of complex left ventricular outflow tract obstruction in the subaortic, valvar and supravalvular space will be highlighted, illustrating the novel applications of CCT in this patient subset.

Technical Recommendations for Computed Tomography Guidance of Intervention in the Right Ventricular Outflow Tract: Native RVOT, Conduits, and Bioprosthetic Valves

This consensus document for the performance of cardiovascular computed tomography (CCT) to guide intervention in the right ventricular outflow tract (RVOT) in patients with congenital heart disease (CHD) was developed collaboratively by pediatric and adult interventionalists, surgeons, and cardiac imagers with expertise specific to this patient subset. The document summarizes definitions of RVOT dysfunction as assessed by multimodality imaging techniques and reviews existing consensus statements and guideline documents pertaining to indications for intervention. In the context of this background information, recommendations for CCT scan acquisition and a standardized approach for reporting prior to surgical or transcatheter pulmonary valve replacement are proposed and presented. It is the first Imaging for Intervention collaboration for CHD patients and encompasses imaging and reporting recommendations prior to both surgical and percutaneous pulmonary valve replacement.

Diagnostic Value of Computed Tomography Angiography for Infective Endocarditis After Right Ventricle Outflow Tract Repair

Congenital heart disease patients with pulmonary valve replacement or right ventricle-pulmonary artery conduit have increased risk of pulmonary valve endocarditis. We present a 6-patient case series illustrating the diagnostic utility of computed tomography angiography to provide definitive visualization of pulmonary valve vegetation to aid in the diagnosis of endocarditis. (Level of Difficulty: Intermediate.).

Proposed competencies for the performance of cardiovascular computed tomography in pediatric and adult congenital heart disease

Cardiovascular computed tomography (CCT) is rated appropriate by published guidelines for the initial evaluation and follow up of congenital heart disease (CHD) and is an essential modality in cardiac imaging programs for patients of all ages. However, no recommended core competencies exist to guide CCT in CHD imaging training pathways, curricula development, or establishment of a more formal educational platform. To fill this gap, a group of experienced congenital cardiac imagers, intentionally inclusive of adult and pediatric cardiologists and radiologists, was formed to propose core competencies fundamental to the expert-level performance of CCT in pediatric acquired and congenital heart disease and adult CHD. The 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography (1) for adult imaging were used as a framework to define pediatric and CHD-specific competencies. Established competencies will be immediately relevant for advanced cardiac imaging fellowships in both cardiology and radiology training pathways. Proposed future steps include radiology and cardiology society collaboration to establish provider certification levels, training case-volume recommendations, and continuing medical education (CME) requirements for expert-level performance of CCT in pediatric and adult CHD.

Multi-institution Assessment of the Accuracy of Cardiac Computed Tomography in Preparation for Superior Cavopulmonary Connection

BACKGROUND

Patients with single ventricle (SV) congenital heart disease (CHD) undergo several interventions in the first years of life. Advanced diagnostics are required for interstage assessment of anatomy, but are associated with significant diagnostic risk. We sought to evaluate image quality, risk, and accuracy of cardiac computed tomography (CCT) for evaluation of anatomy prior to superior cavopulmonary connection (SCPC) compared to surgical findings across 2 institutions.

METHODS

A retrospective evaluation of image quality, risk, and accuracy of pre-SCPC CCT was performed at 2 institutions between January 1, 2010 and September 30, 2016.

RESULTS

CCT was performed in 90 SV CHD patients with a median age of 4.03 months (interquartile range [IQR] 3.36, 5.33) prior to SCPC. Image quality was optimal (84%) or good (16%) in all patients, without significant discrepancy compared to surgical findings. 7 patients (8%) required interventional cardiac catheterization subsequent to CCT and before surgical intervention. 49% of scans were performed without sedation, 43% of scans were performed with mild to moderate sedation, and 8% of scans were performed with general anesthesia. The median total procedural dose-length product (DLP) was 18 (IQR 14, 26) mGy*cm, estimating an age adjusted radiation dose of 1.4 millisievert (mSv). One minor (1%) adverse event was reported within 24 h of the CCT. Surgical complications were unrelated to the presurgical findings.

CONCLUSIONS

CCT for pre-SCPC evaluation is safe, with excellent accuracy for anatomy at the time of surgical intervention across 2 institutions. In select patients, noninvasive evaluation with CCT may be indicated.

Safety, Efficacy, and Dose Protocol of Metoprolol for Heart Rate Reduction in Pediatric Outpatients Undergoing Cardiac CT Angiography

Fundamento

Qualidade de imagem e dose de radiação são otimizadas com uma frequência cardíaca (FC) lenta e estável na realização de imagens de artérias coronárias durante a angiografia cardíaca por tomografia computadorizada (CCTA, do inglês cardiac computed tomography angiography ) A segurança, a eficácia e o protocolo para a redução da FC com medicamento betabloqueador ainda não foi bem descrita em uma população de pacientes pediátricos.

Objetivo

Oferecer um protocolo de dose de metoprolol eficiente a ser usado em pacientes pediátricos externos durante a CCTA.

Métodos

Realizamos uma revisão retrospectiva de todos os pacientes pediátricos externos que receberam o metoprolol durante a CCTA. As características demográficas e clínicas foram resumidas e a redução média em FC foi estimada utilizando-se um modelo de regressão linear multivariada. As imagens foram avaliadas em uma escala de 1 a 4 (1= ideal).

Resultados

Um total de 78 pacientes externos passaram a uma CCTA com o uso de metoprolol. A média de idade foi de 13 anos, a média de peso foi de 46 kg, e 36 pacientes (46%) eram do sexo masculino. As doses médias de metoprolol foram 1,5 (IQR 1,1; 1,8) mg/kg, e 0,4 (IQR 0,2; 0,7) mg/kg para administrações orais e intravenosas, respectivamente. O produto dose-comprimento por exame foi de 57 (IQR 30, 119) mGy*cm. A redução média da FC foi 19 (IQR 12, 26) batimentos por minuto, ou 23%. Não foram relatadas complicações ou eventos adversos.

Conclusão

O uso de metoprolol num cenário de pacientes pediátricos externos para redução da FC antes de uma CCTA é seguro e eficiente. Pode-se reproduzir um protocolo de dose de metoprolol quando for necessário atingir uma FC mais lenta, garantindo tempos de aquisição mais rápidos, imagens mais claras e redução na exposição à radiação nessa população. (Arq Bras Cardiol. 2021; 116(1):100-105)

Multimodality Assessment of Anomalous Aortic Origin of the Right Coronary Artery Presenting With Cardiac Arrest

Anomalous aortic origin of coronary artery (AAOCA) can range from benign anatomic variants to those presenting with sudden cardiac arrest. This unique case of right AAOCA demonstrates detailed anatomic findings from cardiac computed tomography and the effects of transient acute coronary ischemia by cardiac magnetic resonance. (Level of Difficulty: Advanced.)

ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography

The American College of Cardiology (ACC) collaborated with the American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Pediatric Echocardiography to develop Appropriate Use Criteria (AUC) for multimodality imaging during the follow-up care of patients with congenital heart disease (CHD). This is the first AUC to address cardiac imaging in adult and pediatric patients with established CHD. A number of common patient scenarios (also termed "indications") and associated assumptions and definitions were developed using guidelines, clinical trial data, and expert opinion in the field of CHD.1 The indications relate primarily to evaluation before and after cardiac surgery or catheter-based intervention, and they address routine surveillance as well as evaluation of new-onset signs or symptoms. The writing group developed 324 clinical indications, which they separated into 19 tables according to the type of cardiac lesion. Noninvasive cardiac imaging modalities that could potentially be used for these indications were incorporated into the tables, resulting in a total of 1,035 unique scenarios. These scenarios were presented to a separate, independent panel for rating, with each being scored on a scale of 1 to 9, with 1 to 3 categorized as "Rarely Appropriate," 4 to 6 as "May Be Appropriate," and 7 to 9 as "Appropriate." Forty-four percent of the scenarios were rated as Appropriate, 39% as May Be Appropriate, and 17% as Rarely Appropriate. This AUC document will provide guidance to clinicians in the care of patients with established CHD by identifying the reasonable imaging modality options available for evaluation and surveillance of such patients. It will also serve as an educational and quality improvement tool to identify patterns of care and reduce the number of Rarely Appropriate tests in clinical practice.

Development of a congenital cardiovascular computed tomography imaging registry: Rationale and implementation

BACKGROUND

The cumulative exposure and risk of anesthesia, vascular access, contrast agents and radiation is emerging as a significant lifelong burden in patients with congenital heart disease (CHD). Latest generation computerized tomographic (CT) scanners are increasingly used for high resolution cardiovascular imaging and have both hardware and post processing radiation dose reduction strategies that can be implemented. Currently, these dose reduction strategies are not uniformly applied and there is a large variability in radiation dose used for the performance of CT in CHD.

METHODS

We propose the development and implementation of a prospective, multi-center and multi-specialty consortium to measure the variability of use, risk and image quality of CT scans in patients of all ages with CHD. The primary goals of this collaboration are 1) define variability of use, diagnostic quality, and risk of cardiac CT 2) establish best practice guidelines designed to optimize diagnostic image quality with appropriate use of radiation and anesthesia exposure 3) provide institution specific feedback compared with the group norm across participating centers 4) improve the level of evidence for the use of CT in CHD through the collection of prospective and multi-institutional data.

CONCLUSIONS

Prospective multi-institutional data is needed to inform risk estimates of CT in CHD using current generation scanners and aggressive dose optimization techniques. This registry will provide a platform for future collaboration establishing a multi-modality risk assessment tool specific to patients with CHD.

Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently 'Have-A-Heart' campaign

Children with congenital or acquired heart disease can be exposed to relatively high lifetime cumulative doses of ionizing radiation from necessary medical imaging procedures including radiography, fluoroscopic procedures including diagnostic and interventional cardiac catheterizations, electrophysiology examinations, cardiac computed tomography (CT) studies, and nuclear cardiology examinations. Despite the clinical necessity of these imaging studies, the related ionizing radiation exposure could pose an increased lifetime attributable cancer risk. The Image Gently "Have-A-Heart" campaign is promoting the appropriate use of medical imaging studies in children with congenital or acquired heart disease while minimizing radiation exposure. The focus of this manuscript is to provide a comprehensive review of radiation dose management and CT performance in children with congenital or acquired heart disease.

Radiation Safety in Children With Congenital and Acquired Heart Disease: A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance

There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.

SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: A report of the society of Cardiovascular Computed Tomography Guidelines Committee: Endorsed by the North American Society for Cardiovascular Imaging (NASCI)

In response to recent technological advancements in acquisition techniques as well as a growing body of evidence regarding the optimal performance of coronary computed tomography angiography (coronary CTA), the Society of Cardiovascular Computed Tomography Guidelines Committee has produced this update to its previously established 2009 "Guidelines for the Performance of Coronary CTA" (1). The purpose of this document is to provide standards meant to ensure reliable practice methods and quality outcomes based on the best available data in order to improve the diagnostic care of patients. Society of Cardiovascular Computed Tomography Guidelines for the Interpretation is published separately (2). The Society of Cardiovascular Computed Tomography Guidelines Committee ensures compliance with all existing standards for the declaration of conflict of interest by all authors and reviewers for the purpose ofclarity and transparency.

Diagnostic Value of Contrast-Enhanced Multiphase Computed Tomography for Assessment of Percutaneous Pulmonary Valve Obstruction

Percutaneous pulmonary valve replacement has emerged as an alternative to operation for some patients with congenital heart disease requiring intervention. Endocarditis is increasingly described as an adverse event during follow-up [1-4]. Diagnosis is difficult because of the poor visualization of the prosthetic valve in the pulmonary position by transthoracic and transesophageal echocardiogram and by the metallic artifact that degrades the image quality of magnetic resonance imaging (MRI). Two cases of percutaneous pulmonary valve obstruction diagnosed by cardiac computed tomographic angiography are presented. These cases demonstrate the utility of cardiac computed tomography for noninvasive imaging of suspected thrombus or endocarditis in a percutaneously placed pulmonary valve.

Radiation dose and image quality of 70 kVp functional cardiovascular computed tomography imaging in congenital heart disease

BACKGROUND

The use of cardiac computed tomography (CT) for quantification of ventricular function is limited by relatively high radiation dose.

OBJECTIVES

The goal of this study was to describe the radiation exposure and image quality of 70 kVp functional cardiac CT in patients with congenital heart disease (CHD).

METHODS

A retrospective review of 70 kVp ECG gated functional CT scans using tube current modulation was performed in CHD patients at a single institution. Quantitative and qualitative (assessed by myocardial segment, 1-4; 1 = optimal) image quality was determined. Per segment image quality was compared between thin (1.5 mm) and thick (8 mm) reconstructions and by patient age and size. Scan DLP was used to estimate radiation dose.

RESULTS

72 scans were performed during the time of review (7/2013-6/2015). Median patient age was 19.5 years (8.0, 27.1) and BMI was 20.1 (16.6, 24.5) kg/m(2). Median functional scan DLP was 78.8 (45.5, 98) and unadjusted and adjusted procedural mSv were 1.10 (0.64, 1.37) and 1.13 (0.90, 1.37). Image quality of 1 was achieved in all myocardial segments in >75% of scans. Patients with a weight ≥75 kg were more likely to have a scan achieve optimal image when using thick reconstructions compared to thin (81.3% vs. 43.8%; p = 0.028).

CONCLUSIONS

Imaging of ventricular function with 70 kVp in CHD patients can be done with low radiation doses and provides diagnostic image quality, particularly for patients <75 kg. In larger patients, thicker slice reconstruction improved image quality.

Coronary computed tomographic angiographic findings in patients with Kawasaki disease

Kawasaki disease (KD) is the leading cause of acquired coronary disease in children and may lead to subsequent myocardial ischemia and infarction. Because coronary computed tomographic angiography (CTA) is the most sensitive noninvasive test in patients with atherosclerosis, the aim of this study was to retrospectively evaluate coronary CTA performed in patients with KD for aneurysm, stenosis, and calcified and noncalcified coronary artery disease (CAD). Clinical histories and prior stress and imaging test results were reviewed. Thirty-two patients underwent coronary CTA for KD, and 385 coronary segments were evaluated. Twenty-three of 32 patients had ≥1 diseased coronary segment. There were 20 aneurysms, 7 lesions, and 75 segments (20%) with nonobstructive CAD (16% noncalcified, 2% calcified, and 2% mixed). All nonobstructive and obstructive CAD was in patients with histories of acute-phase coronary artery dilatation or aneurysm (echocardiographic z score 4 to 44), and were almost always associated with normal stress imaging test results on follow-up. No lesion or CAD was found in coronary computed tomographic angiographic studies performed in a control group referred for other indications (n = 32, 422 segments evaluated). The median coronary computed tomographic angiographic dose-length product was 59 mGy cm (interquartile range 32 to 131), the median unadjusted radiation dose was 0.8 mSv (interquartile range 0.4 to 1.8), and the median age- and size-adjusted radiation dose was 1.3 mSv (interquartile range 0.7 to 2.3). In conclusion, high-risk patients with histories of KD had nonobstructive and obstructive CAD not visualized by other noninvasive imaging tests. In properly selected high-risk patients with KD, coronary CTA may identify a subset at increased risk for future coronary pathology who may benefit from medical therapy.

Use of cardiac CT angiography to assist in the diagnosis and treatment of aortic prosthetic paravalvular leak: a practical guide

Percutaneous repair of aortic paravalvular regurgitation can help avoid the need for repeat valve surgery. Although the initial diagnosis of paravalvular regurgitation is usually made with echocardiography, cardiac CT angiography helps to determine the site and morphology of these leaks. The utility of CT is highly dependent on the quality of the data. Herein, we describe a systematic approach to image acquisition and interpretation of cardiac CT angiography in patients with aortic paravalvular regurgitation, which integrates findings from echocardiography. This approach can be used to minimize inaccuracies in the diagnosis and enhance the procedural success for percutaneous repair of aortic paravalvular regurgitation.

Selective use of cardiac computed tomography angiography: an alternative diagnostic modality before second-stage single ventricle palliation

OBJECTIVES

To assess the accuracy and risk of substituting cardiac computed tomography for cardiac catheterization in select patients for evaluation of anatomy before second-stage single ventricle palliation.

METHODS

This is a retrospective review of consecutive diagnostic cardiac catheterization (n=16) and computed tomography studies (n=16) performed before second-stage single ventricle palliation from March 2010 to July 2012 at a single institution. Risk (anesthesia, vascular access, contrast, and radiation exposure), accuracy, and postoperative course were compared. Nonparametric analysis was used to compare differences in group medians.

RESULTS

General anesthesia was used for 16 of 16 cardiac catheterization studies and 1 of 16 computed tomography studies. Vascular access was central venous and/or arterial for all cardiac catheterization studies and a peripheral intravenous line for all computed tomography studies. Median age- and size-adjusted radiation dose was 14.0 mSv for cardiac catheterization and 1.1 mSv for computed tomography. Contrast dose was 4.8 mL/kg for the cardiac catheterization group and 2 mL/kg for the computed tomography group. There were no computed tomography discrepancies and 1 discrepancy between cardiac catheterization and surgical findings. There were 8 adverse events in 6 patients in the cardiac catheterization group and 1 adverse event in the computed tomography group. There was no difference between groups in postoperative course or need for repeat intervention.

CONCLUSIONS

Cardiac computed tomography and cardiac catheterization are equally accurate for evaluation of anatomy before second-stage single ventricle palliation when compared with surgical findings. Computed tomography may be the preferred test in select patients because of decreased vascular access and anesthesia risk, lower radiation and contrast exposure, and fewer adverse events.

Cardiovascular imaging trends in congenital heart disease: a single center experience

BACKGROUND

Cardiac magnetic resonance imaging (MRI) and CT are available in the recent era at many pediatric cardiac centers.

OBJECTIVE

The aim was to provide a contemporary description of diagnostic imaging trends for definition of congenital heart disease (CHD).

METHODS

Echocardiography, cardiac catheterization, cardiac MRI, and cardiac CT use in patients with congenital heart disease at a single institution was retrospectively recorded (2005-2012). Surgical procedures were recorded. Total and modality-specific rates were estimated by Poisson regression and compared. The median age, studies in patients aged >17 years, and referral diagnosis were tabulated for the last year of review.

RESULTS

An average of 11,940 cardiovascular diagnostic tests was performed annually. The number of total studies, echocardiograms, catheterizations, and surgical procedures, did not change significantly across time. Echocardiography comprised 95% to 97% of all studies performed during each year of review. The use of cardiac MRI (2%) and cardiac CT (1%) increased linearly (P < .001), and the use of diagnostic catheterization decreased (0.7%; P = .0005). The median age was 3 years for echocardiography, 15 years for MRI, 11 years for CT, and 3 years for catheterization. The percentage of patients aged >17 years was 9% for echocardiography, 33% for cardiac MRI, 29% for cardiac CT, and 8% for catheterization. Most patients undergoing CT, MRI, and diagnostic catheterization had moderate or complex CHD.

CONCLUSION

Cardiac CT is used increasingly in the recent era for evaluation of CHD. The increased use of both cardiac CT and cardiac MRI are temporally associated with a decrease in diagnostic cardiac catheterization.

Clinical presentations and outcomes of systemic lupus erythematosus patients with infection admitted to the intensive care unit

Objective

The objective of this article is to investigate clinical presentations and outcomes of systemic lupus erythematosus (SLE) patients with infection admitted to the intensive care unit (ICU).

Methods

SLE patients with infection, SLE patients with noninfectious causes, and non-SLE patients with infection were identified from the Cooper University Hospital Project IMPACT database between 2002 and 2010. We examined demographic data, APACHE II scores, physiologic data, laboratory data, length of stay in the ICU and hospital, and mortality of the three groups.

Results

Twenty-five SLE patients with infection, 45 SLE patients with noninfectious causes, and 1466 non-SLE patients with infection were included in the study. SLE patients with infection had higher APACHE II scores, higher maximum temperature, higher minimum and maximum heart rate (HR), lower minimum and maximum systolic blood pressure (SBP), and longer ICU length of stay in comparison to SLE patients with noninfectious causes. There were no statistical differences in white blood cell (WBC) count. SLE patients with infection had a higher mortality compared to SLE patients with noninfectious causes. There was no difference in mortality between SLE patients with infection and non-SLE patients with infection.

Conclusion

SLE patients with infection in the ICU had a higher mortality and a higher APACHE II score compared to SLE patients with noninfectious causes in the ICU. Their physiologic signs including temperature, HR, and SBP were more reflective of infection than their WBC count.

Evaluation of ER and Ki-67 proliferation index as prognostic factors for survival following neoadjuvant chemotherapy with doxorubicin/docetaxel for locally advanced breast cancer

BACKGROUND

The aim of the study was to identify reliable predictive biological markers for treatment outcome following neoadjuvant adriamycin/docetaxel (AT) chemotherapy in locally advanced breast cancer patients.

MATERIALS AND METHODS

This study was a phase II study on AT neoadjuvant chemotherapy in locally advanced breast cancer patients. Patients received 50 mg/m(2) of doxorubicin intravenously (IV) over 15 min followed by docetaxel 75 mg/m(2) infused over 1 h, repeated every 3 weeks for three cycles. Surgery was performed within 3-4 weeks following the last cycle of chemotherapy. We analyzed the pre-treatment and post-treatment expression levels of ER, PgR, HER-2, Ki-67 proliferation index, and p53 and examined the correlation between the markers and clinical parameters with treatment response, overall survival and relapse-free survival following neoadjuvant treatment.

RESULTS

From July 2001 to September 2004, 61 patients were enrolled. The meaningful parameters adversely influencing survival were post-treatment ER(-) status (P = 0.013) and post-treatment Ki-67 index above 1.0% (P = 0.013). At the multivariate level, the post-treatment Ki-67 proliferation index < or = 1.0 was the only meaningful prognostic factor for better survival (P = 0.033). Notably, tumors with Ki-67 index < or = 1.0 were more likely to express ER with statistical significance (P = 0.002). Tumors with ER(+) and Ki-67 index < or = 1.0 showed the highest survival rate, followed by ER(+) and Ki-67 index > 1.0%, ER(-) and Ki-67 < or = 1.0%, and ER(-) and Ki-67 > 1.0% with the worst survival (P = 0.033).

CONCLUSION

Collectively, post-treatment ER status and Ki-67 proliferation index were prognostic of overall survival following neoadjuvant AT chemotherapy.

Value of repeat ultrasound-guided fine-needle aspiration in nodules with benign cytological diagnosis

PURPOSE

To assess the value of repeat ultrasound-guided fine-needle aspiration (US-FNA) in nodules with benign cytological diagnosis.

MATERIAL AND METHODS

One-hundred-and-eighty-seven patients undergoing repeat US-FNA were included after a benign cytological diagnosis had been made by the initial US-FNA. They were divided into a re-aspiration group, who underwent repeat US-FNA within 6 months for a discordant pathological and clinico-radiological result, and a follow-up aspiration group, who underwent repeat US-FNA after 6 months without any clinical or radiological suspicion. The cancer rate in each group and the US findings of the later-diagnosed malignant nodules were assessed.

RESULTS

Nine malignancies were verified in the 187 cases (4.8%) by repeat US-FNA or surgery. In 44 patients in the re-aspiration group, 6 malignancies were identified (13.6%), compared with 3 malignancies in the 143 patients in the follow-up aspiration group (2.1%) (P<0.05). The later-diagnosed malignant nodules were an average of 1.0 cm in diameter; 66.7% were round; 66.7% were circumscribed; 100% were solid; 88.9% were hypoechoic; and 55.6% contained calcifications on US.

CONCLUSION

The follow-up of nodules with benign cytological diagnosis without clinicoradiological suspicion of malignancy is warranted using imaging surveillance rather than repeated US-FNA.

Increased prevalence of activated CD70+CD4+ T cells in the periphery of patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is characterized by loss of immune tolerance. A hallmark of SLE is the presence of autoantibodies resulting from B cell hyperactivity. Previous studies have shown that the presence of abnormal B cell subsets in the periphery, such as CD27highCD20- B cells, correlate with disease activity. We examined the relationship between the expression of CD70, the ligand for CD27 expressed by activated T cells, and indicators of disease activity. A significant increase in median CD70+CD4+ T cell frequencies and memory CD45RA-CD4+ T cell frequencies was observed in SLE samples as compared to healthy controls. The frequencies of CD70+CD4+ T cells correlated with disease duration but not age, treatment, or disease activity. Although a majority of CD70+CD4+ T cells appeared to be effector memory cells, mitogen-stimulated CD70+CD4+ T cells were capable of secreting a full repertoire of effector cytokines. Despite the presence of activated CD4+ T cells, no increase in immunosenescent CD4+ T cells, as defined by the loss of CD28 and/or the acquisition of CD57 was observed in samples from SLE patients. These studies indicate that increased CD70 expression might serve as a useful marker of abnormal T cell activity in SLE.

Identification and characterization of the peroxiredoxin gene family in chickens

Peroxiredoxin (PRX) is a crucial antioxidant protein that protects against endogenously produced peroxides in prokaryotes to eukaryotes. To date, 6 different isoforms have been identified in mammals. In this study, we describe the first members of the PRX protein family to be characterized in Chicken. Through bioinformatics analysis, we observed that at least 4 different classes of PRX protein have been evolutionarily conserved in chickens. Furthermore, in vitro functional assays of the candidate chicken PRX proteins demonstrated that they had levels of antioxidant activity similar to those of the mammalian enzymes. The expression patterns of the PRX transcript in several chicken tissues were not tissue specific, suggesting that they might play an essential role as a housekeeping gene in all tissues to protect against oxidative damage. In conclusion, the sequences of the putative members of this functional gene family in chickens could be effectively retrieved in silico through bioinformatics analysis, and the functionality of their gene products evaluated by in vitro comparative assay.

A set of testis-specific novel genes collected from a collection of Korean Native Chicken ESTs

We report a set of testis-specific novel genes by comparing the The Institute for Genomic Research (TIGR) chicken gene index with the 13,132 expressed sequence tag (EST) collection from Korean Native Chicken (KNC). A total of 553 novel transcripts have resulted after comparison of our EST contigs and singlets against the chicken gene index and chicken genome sequences. Interestingly, 76% of the new genes were from testis-specific EST contigs or singlet and analysis of exon/intron structure showed that a significant number of the contigs have intronless coding regions. A large portion of the testis-specific transcripts have intronless coding region indicating that the testis-specific expression pattern is related to a group of single exon genes in the chicken. The chicken EST data that are described in this paper have been submitted to the NCBI dbEST under accession numbers CO759017-CO764274, CO765331-CO768903 and CO769672-CO773972.

Thymic ultrasound. I. Intrathymic anatomy in infants

BACKGROUND

The gross appearance and echogenicity of the normal thymus have been described, but specific intrathymic anatomy has not been evaluated with imaging.

SUBJECTS AND METHODS

The thymus from a 34-week-gestation stillborn male was examined with ultrasound, and the images were correlated with microscopic findings. Thymic ultrasound was performed in 12 infants without any evidence of thymic abnormality, severe infection, or chronic illness. Images were evaluated focusing on intrathymic parenchymal anatomy and compared to the liver, spleen, and thyroid gland.

RESULTS

In the specimen thymus, ultrasound demonstrated connective-tissue septa as echogenic linear structures. The cortex was relatively hypoechoic, whereas the medulla was echogenic. The blood vessels within the septa were seen as discrete echoes. In vivo ultrasound demonstrated multiple branching echogenic linear structures and foci throughout the parenchyma, representing connective-tissue septa or blood vessels within the septa. The normal thymus was easily differentiated from the liver, spleen, and thyroid glands.

CONCLUSION

Ultrasound is capable of demonstrating intrathymic anatomy, including the medulla, cortex, septa, and blood vessels in a fresh specimen. In vivo connective-tissue septa and blood vessels in the thymic parenchyma produce a unique echo pattern.

Thymic ultrasound. II. Diagnosis of aberrant cervical thymus

BACKGROUND

The aberrant cervical thymus is an uncommon entity to be considered in the differential diagnosis of neck masses in children, so a preoperative diagnosis has rarely been made.

OBJECTIVE

The purpose of this study was to assess the ultrasound features of aberrant cervical thymus and determine if recognition of the previously described unique intrathymic echo pattern allows us to make a specific diagnosis.

MATERIALS AND METHODS

We present four patients with an aberrant cervical thymus and one patient with a cervical thymic cyst. All five patients had ultrasound, which was evaluated with special attention to the detailed echo pattern of the mass. In two patients, the mass was surgically removed. Four patients had MRI, which was evaluated. Medical records were reviewed.

RESULTS

In all cases, the mass was painless and nontender. All occurred in the expected path of the thymopharyngeal duct. In four patients, ultrasound demonstrated multiple echogenic linear structures and foci previously described as characteristic echo pattern of normal thymic tissue. In one patient, ultrasound showed a large cystic mass and echogenic solid component superiorly with a characteristic echo pattern of normal thymus.

CONCLUSIONS

The ultrasound appearance of thymic tissue is unique, allowing a specific diagnosis of aberrant cervical thymus. Biopsy or other imaging is probably not indicated when it presents with typical clinical features.

Mediastinal interfaces and lines in children: radiographic-CT correlation

BACKGROUND

Various mediastinal interfaces and lines are well known in adults, but not fully understood in children.

OBJECTIVE

To review the mediastinal interfaces and lines on plain radiographs in the paediatric age group with CT correlation.

MATERIALS AND METHODS

Soft copies of 195 sets of CT examinations and concurrent chest radiographs in 180 paediatric patients (age 1 month to 15 years) were retrospectively reviewed. The frequency of visualisation and the anatomical basis of the mediastinal interfaces and lines were assessed. The evaluated mediastinal interfaces and lines were superior vena cava interface, descending aorta interface, left paraspinal interface, azygoesophageal recess interface, right paratracheal stripe, anterior junction line and posterior junction line.

RESULTS

Chest radiographs showed the SVC interface in 161, the descending aorta interface in 155, the left paraspinal interface in 98, the azygoesophageal recess in 94, the right paratracheal stripe in 53, the anterior junction line in 15 and the posterior junction line in 10. Non-visualisation of mediastinal interfaces and lines on plain radiographs was explained by normal anatomical difference compared with the adult and underlying intrathoracic abnormalities when they were correlated with CT. The frequency of visualisation of the SVC interface, descending aortic interface, left paraspinal interface and azygoesophageal recess fluctuated with age, while the frequency of the right paratracheal stripe, anterior junction line and posterior junction line increased with age.

CONCLUSIONS

Awareness of the frequency of visualisation and the anatomical basis of the mediastinal interfaces and lines in paediatric patients may be helpful for interpretation of chest radiographs.

Expression of p21Waf1, p27Kip1 and cyclin D1 proteins in breast ductal carcinoma in situ: Relation with clinicopathologic characteristics and with p53 expression and estrogen receptor status

p21Waf1 (p21), p27Kip1 (p27) and cyclin D1 have recently been reported as useful prognostic markers for patients with breast carcinoma. However, studies on these cell cycle regulators in ductal carcinoma in situ (DCIS) have been extremely limited. Therefore, we studied the immunohistochemical expression of p21, p27 and cyclin D1 proteins in 49 DCIS cases and compared the findings with the clinicopathologic parameters (age, tumor size, gross type, histologic type, histologic grade, necrosis and mitotic index), p53 and estrogen receptor (ER) status. A significant correlation was found between positive p21 immunoreactivity (67.3% of the cases) and well-differentiated histologic grade, non-comedo type, ER-positive and p53-negative (p53-) status. DCIS with p21+/p53- is likely to be the non-comedo type. The overexpression of cyclin D1 (59.2% of the cases) correlated positively with the ER expression (P = 0.001). The p27 protein expression (46.9% of the cases) correlated with the cyclin D1 immunopositivity (P = 0.0003) and ER expression (P = 0.005). No significant associations were seen in the p27 or cyclin D1 expression and other clinicopathologic parameters. Our results suggest that p21 might be more related to the useful biologic markers in DCIS than p27 or cyclin D1. The significant positive association between p21, p27 or cyclin D1 and ER status, and close association of p27 and cyclin D1 expression might be implicated in the tumor biology of DCIS.

Foreign body granulomas of the breast presenting as bilateral spiculated masses

In Asia, mammography following the injection of foreign materials into the breasts for cosmetic augmentation is frequently seen and diagnosis based on the typical radiologic findings is straightforward. We report the unusual radiologic findings in two patients with foreign body granulomas caused by injected foreign materials and discovered incidentally during screening work up. The mammographic findings were bilateral, hyperdense, spiculated masses, with occasional microcalcification, and at sonography, markedly hypoechoic, spiculated solid masses, located near the pectoralis muscle and partly extending into it, were observed. These radiologic findings mimicked malignancy.