Gated cardiac CT in infants: What can we expect from deep learning image reconstruction algorithm?

BACKGROUND

ECG-gated cardiac CT is now widely used in infants with congenital heart disease (CHD). Deep Learning Image Reconstruction (DLIR) could improve image quality while minimizing the radiation dose.

OBJECTIVES

To define the potential dose reduction using DLIR with an anthropomorphic phantom.

METHOD

An anthropomorphic pediatric phantom was scanned with an ECG-gated cardiac CT at four dose levels. Images were reconstructed with an iterative and a deep-learning reconstruction algorithm (ASIR-V and DLIR). Detectability of high-contrast vessels were computed using a mathematical observer. Discrimination between two vessels was assessed by measuring the CT spatial resolution. The potential dose reduction while keeping a similar level of image quality was assessed.

RESULTS

DLIR-H enhances detectability by 2.4% and discrimination performances by 20.9% in comparison with ASIR-V 50. To maintain a similar level of detection, the dose could be reduced by 64% using high-strength DLIR in comparison with ASIR-V50.

CONCLUSION

DLIR offers the potential for a substantial dose reduction while preserving image quality compared to ASIR-V.

Plain radiography has a role to play in current clinical practice in Western Switzerland

AIM

The aim of the study was to investigate the current role of conventional radiography examinations in Western Switzerland and the main clinical indications required to justify the use of this imaging examination.

METHODS

Ethical approval was obtained from Vaud Ethics committee (Ref 2020-00311). An online questionnaire was specifically designed and implemented on the data collection tool LimeSurvey composed of two parts: a) to characterise the participants' profile and their institutions and b) 169 projections for the different anatomical area (upper and lower limbs, pelvis, skull, spine, thorax, abdomen) were presented to collect data about the frequency and main clinical indications. Statistical analysis was performed using the software IBM SPSS® (Statistical Package for the Social Sciences) version 26.

RESULTS

Radiographers from 60% (26/43) of the invited institutions participated in this survey, mainly from Vaud region. The upper and lower limbs were the most commonly examined by using conventional radiography mainly for trauma and degenerative disorders. The thorax was also an anatomical area commonly explored by X-rays, so were the spine (cervical and lumbar lateral). The skull radiographs were rarely performed in clinical practice and some of the projections were not being used, namely Hirtz, Tangential Nose Bones, Worms and Caldwell's views.

CONCLUSIONS

Plain radiography is being used in clinical practice mainly for appendicular skeleton studies and for trauma and degenerative pathologies. Adaptations in radiographers' education and training and other healthcare professionals are needed to provide the judicious use of data that radiographs can give to better manage the patients' imaging pathway.

The combination of non-contrast abbreviated MRI and alpha foetoprotein has high performance for hepatocellular carcinoma screening

OBJECTIVES

This study aimed to compare two abbreviated MRI (AMRI) protocols to complete MRI for HCC detection: non-contrast (NC)-AMRI without/with alpha foetoprotein (AFP) and dynamic contrast-enhanced (Dyn)-AMRI.

METHODS

This retrospective single-center study included 351 patients (M/F: 264/87, mean age: 57y) with chronic liver disease, who underwent MRI for HCC surveillance between 2014 and 2020. Two reconstructed AMRI sets were obtained based on complete MRI: NC-AMRI (T2-weighted imaging (WI) + diffusion-WI) and Dyn-AMRI (T2-WI + dynamic T1-WI) and were assessed by 2 radiologists who reported all suspicious lesions, using LI-RADS/adapted LI-RADS classification. The reference standard was based on all available patient data. Inter-reader agreement was assessed and MRI diagnostic performance was compared to the reference standard.

RESULTS

The reference standard demonstrated 83/351 HCC-positive patients (prevalence: 23.6%, median size: 22 mm, and positive MRIs: 83/631). Inter-reader agreement was substantial for all sets. Sensitivities of Dyn-AMRI and complete MRI (both 92.8%) were similar, higher than NC-AMRI (72.3%, p < 0.001). Specificities were not different between sets. NC-AMRI + AFP (92.8%) had similar sensitivity to Dyn-AMRI and complete MRI. In patients with small size HCCs (≤ 2 cm), sensitivities of Dyn-AMRI (85.3%) and complete MRI (88.2%) remained similar (p = 0.564), also outperforming NC-AMRI (52.9%, p < 0.05). NC-AMRI + AFP had similar sensitivity (88.2%) to Dyn-AMRI and complete MRI (p = 0.706 and p = 1, respectively).

CONCLUSIONS

Dyn-AMRI has similar diagnostic performance to complete MRI for HCC detection, while both outperform NC-AMRI, especially for small size HCCs. NC-AMRI + AFP demonstrates similar sensitivity to Dyn-AMRI and complete MRI.

CLINICAL RELEVANCE STATEMENT

Due to the low sensitivity of ultrasound for hepatocellular screening, new screening methods are needed. Abbreviated MRI (AMRI) is a candidate, especially non-contrast AMRI with serum alpha foetoprotein as the acquisition time is low, without the need for contrast medium injection.

KEY POINTS

• Dynamic contrast-enhanced abbreviated MRI using extracellular gadolinium-based contrast agent and complete MRI have similar diagnostic performance for hepatocellular carcinoma detection in an at-risk population. • Non-contrast abbreviated MRI with alpha foetoprotein has similar diagnostic performance to dynamic contrast-enhanced abbreviated MRI and complete MRI, including when considering small size hepatocellular carcinoma  ≤ 2 cm. • Non-contrast abbreviated MRI and dynamic contrast-enhanced abbreviated MRI can be performed in 7 and 10 min, excluding patient setup time.

P6556Prevention of long-lasting atrial fibrillation through device therapy in dual-chamber pacemakers: analysis on 1384 patients of the role of Reactive ATP and atrial preventive pacing

Background

Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in clinical practice and it is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. Moreover AF management is a huge cost for healthcare systems. AF is irregular, typically originates from the pulmonary veins, and as such, requires cardioversion to terminate persistent episodes. AF is not susceptible to pace-termination, however, the MINERVA trial has shown that AF may transform in slower organized rhythms such as atrial flutter or atrial tachycardia, which can often be terminated by atrial anticahycardia pacing (ATP); in particular by Reactive ATP, a specific ATP feature which can be re-armed when atrial arrhythmias get slower or more regular. The MINERVA trial showed that the combination of ATP, preventive atrial pacing algorithms and minimal ventricular pacing (MVP) was associated with lower progression to persistent and permanent AF, compared with standard DDD pacing mode and to MVP mode, in pacemaker patients with clinical history of AF.

Purpose

We aimed to confirm MINERVA trial results in real-world clinical practice and to evaluate whether AF prevention was associated with preventive atrial pacing or solely with ATP. Indeed in our project atrial preventive pacing algorithms were not enabled and the pacing mode (DDD or MVP) was chosen according to patients' AV conduction characteristics.

Methods

Consecutive dual-chamber pacemaker patients with sinus node disease and device detected AT/AF were prospectively followed by 30 Italian cardiologic centers in an observational research. Clinical and device data were collected and reviewed by expert cardiologists to assess AT/AF occurrence through in clinic visit and/or remote transmissions of device data.

Results

A total of 239 patients (73 years old, 56% male) wearing a dual-chamber pacemaker with Reactive ATP were included in the project, followed for a median observation period of 13 months and compared with 1145 patients included in the MINERVA trial followed for a median observation period of 34 months and programmed with DDD pacing mode (383 patients), MVP (389 patients) and MVP+Reactive ATP+preventive algorithms (373 patients). As shown in the following figure incidence of 7 consecutive days of AF in the patients treated by DDD/MVP+Reactive ATP in real-world clinical practice was very similar to that found in the MINERVA trial arm programmed with MVP+Reactive ATP+preventive algorithms.

Incidence of AF longer than 7 days

Conclusions

Our analysis performed in a population of sinus node disease patients with dual-chamber pacemakers confirmed MINERVA trial results in terms of prevention of long-lasting AF episodes. In particular these results confirm the benefit associated with the use of Reactive ATP, rather than preventive atrial pacing algorithms.

Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology

AIM

To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures.

METHODOLOGY

A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures.

RESULTS

A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered.

CONCLUSIONS

Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Circulating cardiovascular biomarkers in recurrent atrial fibrillation: data from the GISSI-atrial fibrillation trial

OBJECTIVE

we evaluated the prognostic role of circulating cardiovascular biomarkers in patients with a history of recent atrial fibrillation (AF).

BACKGROUND

predicting long-term maintenance of sinus rhythm in patients with AF is difficult.

METHODS

plasma concentrations of three specific cardiac markers [high-sensitivity troponin T (hsTnT), N-terminal probrain natriuretic peptide (NT-proBNP) and mid-regional proatrial natriuretic peptide (MR-proANP)] and three stable fragments of vasoactive peptides [mid-regional proadrenomedullin (MR-proADM), copeptin (CT-proAVP) and CT-proendothelin-1 (CT-proET-1)] were measured at baseline and after 6 and 12 months in 382 patients enrolled in the GISSI-AF study, a prospective randomized trial to determine the effect of valsartan to reduce the recurrence of AF. The association between these markers, clinical characteristics and recurrence of AF was tested by univariate and multivariate Cox models.

RESULTS

mean patient age was 68 ± 9 years (37.2% females). A total of 84.8% of patients had a history of hypertension. In total, 59.7% qualified for history of AF because of successful cardioversion, 11.8% because of two or more episodes of AF in the 6 months preceding randomization and 28.5% because of both. Patients in AF at 6 or 12 months (203 (53.1%) with first recurrence) had significantly higher concentrations of most biomarkers. Despite low baseline levels, higher concentrations of hsTnT {adjusted hazard ratio (HR) [95% confidence intervals (CIs) for 1 SD increment] (1.15 [1.04-1.28], P = 0.007), MR-proANP (1.15 [1.01-1.30], P = 0.04), NT-proBNP (1.24 [1.11-1.39], P = 0.0001) and CT-proET-1 (1.16 [1.01-1.33], P = 0.03) independently predicted higher risk of a first recurrence of AF. Changes over time of MR-proANP tended to predict subsequent recurrence (adjusted HR [95%CI]) (1.53 [0.98-2.37], P = 0.06).

CONCLUSION

circulating markers of cardiomyocyte injury/strain and endothelin are related to recurrence of AF in patients in sinus rhythm with a history of recent AF.

[Fascicular ventricular tachycardia]

Fascicular tachycardia is an uncommon idiopathic ventricular tachycardia, originating from the left ventricle; it usually occurs in young male patients, with a high prevalence in south-east Asiatic people. Electrocardiographic aspects of this unique ventricular tachycardia (right bundle branch block morphology and left or right-axis deviation, with a moderate QRS widening) and verapamil sensitivity make it often difficult the differential diagnosis with other forms of supraventricular tachycardia. Reentry is believed to be the operative mechanism of fascicular tachycardia, with the reentrant circuit located in the Purkinje network, in the region of the left posterior or anterior fascicle. The slow conduction zone participating in the reentry circuit, made up of partially depolarized Purkinje fibers, seems to be located in a relatively wide area, from the basal to the apical left interventricular septum. Intravenous verapamil is elective in acute treatment; however oral verapamil shows poor efficacy in preventing tachycardia relapses. Ablative approach is very effective; success is achieved in approximately 90% of patients, with rare complications. Recently diastolic potentials during fascicular tachycardia have been reported and these findings have given rise to new electrophysiological hypotheses and new indications about the successful ablation site.

Calcium antagonist antihypertensive treatment of non-insulin-dependent diabetics: efficacy and safety of lacidipine versus nifedipine SR

Arterial hypertension is a chronic condition regarded as one of the main risk factors for development of coronary atherosclerosis. As dyslipidemia and reduced glucose tolerance are also risk factors for coronary disease, it is considered important to use antihypertensive drugs having no negative effects on lipid and glucose metabolism when diabetic patients are treated for hypertension. Lacidipine, a new dihydropyridine-like calcium antagonist, has been shown in in vivo and in vitro preclinical studies to possess potent, long-lasting antihypertensive activity. The present study compared the efficacy and safety of once-daily treatment with lacidipine versus nifedipine SR given twice-daily in non-insulin-dependent diabetic patients. Results have shown a similar efficacy of the two treatments: 6 months later, both drugs had reduced blood pressure values [lacidipine from 184.8/105.2 mm Hg to 144.4/87.1 mm Hg; nifedipine slow-release (SR) from 182.3/106.8 mm Hg to 143.6/89.4 mmHg]. However, lacidipine exhibited a lower incidence of adverse events (particularly ankle edema and tachycardia) than nifedipine SR. Finally, both treatments showed no negative effect on metabolic parameters (total cholesterol, high-density lipoprotein cholesterol, triglycerides, and blood glucose).

[The role of Doppler echocardiography in assessing left ventricular diastolic function. Case histories]

The aim of this study was to provide a further contribution to evaluate the alterations induced by age on a number of simple Doppler indexes of left ventricular diastolic function. A population of 48 healthy subjects aged between 15 and 78 years old was examined using pulsed Doppler analysis of the left ventricular refilling flow. Linear regression analysis revealed a significant inverse correlation between age and peak speed during rapid refilling (r = -0.80); between age and the ratio between peak speed during rapid refilling and peak during atrial systole (r = -0.92); between age and deceleration time of peak E wave speed, although on the contrary the peak speed of diastolic refilling flow during the atrial systole (r = 0.81) increased significantly with age. Variance analysis showed that indexes of left ventricular diastolic function and age continued on the contrary to be significant n the population as a whole and in both sexes. From these findings it is clear that in the different age groups (15-29, 30-49, 50-65, and over 65) the peak speed of rapid refilling flow was significantly lower in over-65-year-olds than in elderly, middle-aged and young subjects (55 +/- 0.8, 60 +/- 0.5, 65 +/- 0.7 and 75 +/- 0.6 respectively; p < 0.001). The ratio between the peak speed of rapid refilling and that during the atrial systole was lower in over-65-year-olds compared to elderly subjects, middle-aged subjects or the youngest age group (0.94 +/- 0.09, 1.05 +/- 0.13, 1.96 +/- 0.21 and 2.68 +/- 0.50 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[3 cases of gingival hyperplasia during nifedipine therapy]

The authors report the cases of three male patients, aged 36, 54 and 52 years, who developed gingival hypertrophy during treatment with nifedipine at a dose of 40 mg/daily. Hypertrophy was the same as that observed in patients treated with anti-convulsive or cytostatic drugs, and may probably be due to interference with calcium ions and local factors. Full recovery was achieved by suspending nifedipine treatment in all patients.

[The diagnostic value of delta-R and delta-Q as positive criteria of the ergometry test in a group of patients with angina pectoris of effort]

ECG-exercise tests were performed in 29 patients affected by effort chest pain. All patients underwent coronary angiography and/or revealed positive results in the cycloergometer effort test. The aim of the study was to evaluate ultrasonic variations in the R and Q waves due to maximal effort, so as to increase the information provided by the effort ECG. In the coronary angiographic test, 21 out of 29 patients revealed significant hemodynamic coronary stenosis; 10 patients were affected by previous myocardial necrosis; 8 patients showed no hemodynamic coronary lesions (OV). In the OV patients a statistically significant increase was observed in the Q wave at maximal effort in comparison with average basal values; on the other hand, there was a decrease, although not significant, in voltage at peak effort in patients with coronary stenosis. R wave amplitude was smaller in comparison to basal values in OV patients, while a significant increase was observed in the 21 patients with coronary lesions.

Captopril at 50 mg as well as at 100 mg once a day reduces blood pressure for up to 24 h: a double-blind randomized crossover study in mild to moderate hypertensives

The extent and the duration of the antihypertensive effect of captopril, given once a day at a dose of 50 mg, compared with placebo and with the 100 mg once daily dose was studied in 30 mild or moderate uncomplicated essential hypertensives (mean +/- s.e.m. age 52.0 +/- 1.5 years), who responded (mean blood pressure decrease greater than 10%) to a single oral dose (12.5 mg) of captopril. According to a randomized, double-blind, crossover design, they were given 50 mg captopril four times a day, 100 mg captopril four times a day or matched placebo for 1 month. At the end of each treatment period blood pressure and heart rate were measured every 30 min from 3 h before to 2 h after the last dose. Although the heart rate did not change, mean blood pressure after the 50- and 100-mg doses of captopril was consistently significantly (P less than or equal to 0.05) lower than after placebo. The hypotensive effect peaked at the second hour and was still significant 24 h after dosing without any significant differences between the 50- and the 100-mg doses. These findings indicate that captopril, given chronically once a day at a dose of 50 mg to mild to moderate hypertensive responders, exerts its hypotensive effect up to 24 h and that doubling the dose does not increase either the extent or the duration of its action.