Incidence of cryoballoon expansion dislodgement during pulmonary vein isolation-An underappreciated frequent cause of incomplete isolation

BACKGROUND

Cryoballoon ablation for atrial fibrillation (AF) requires adequate contact between the pulmonary vein (PV) antrum and cryoballoon. The surge of intraballoon pressure during the initial phase of ablation may change the balloon's shape and compliance, resulting in balloon dislodgement and loss of PV occlusion. Without continuous monitoring, this phenomenon is often undetected but can be associated with incomplete PV isolation (PVI).

METHODS

Primary cryoablation of AF was performed in 15 patients. PV occlusion status pre- and post-freezing were analyzed with intracardiac echocardiography (ICE) and dielectric imaging-based occlusion tool (DIOT) to calculate the incidence of expansion dislodgement of cryoballoon.

RESULTS

A total of 105 cryoablation applications were performed on 57 veins, including three common ostiums of left pulmonary veins. In the evaluation of PV occlusion, both modalities reported consistent results in 86.7% of the assessments. Despite complete PV occlusion before ablation, peri-balloon leak after initiation of freezing was detected by ICE in 5/22 (22.7%) applications and by DIOT in 8/25 (32%) applications.

CONCLUSION

Incidence of expansion dislodgement of the cryoballoon was detected in one-fourth to one-third of cryoablation applications depending on the imaging modality used, which was clinically frequent and significant.

ACR Appropriateness Criteria® Incidentally Detected Indeterminate Pulmonary Nodule

Incidental pulmonary nodules are common. Although the majority are benign, most are indeterminate for malignancy when first encountered making their management challenging. CT remains the primary imaging modality to first characterize and follow-up incidental lung nodules. This document reviews available literature on various imaging modalities and summarizes management of indeterminate pulmonary nodules detected incidentally. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Lung Cancer Screening: 2022 Update

Lung cancer remains the leading cause of cancer-related mortality for men and women in the United States. Screening for lung cancer with annual low-dose CT is saving lives, and the continued implementation of lung screening can save many more. In 2015, the CMS began covering annual lung screening for those who qualified based on the original United States Preventive Services Task Force (USPSTF) lung screening criteria, which included patients 55 to 77 year of age with a 30 pack-year history of smoking, who were either currently using tobacco or who had smoked within the previous 15 years. In 2021, the USPSTF issued new screening guidelines, decreasing the age of eligibility to 80 years of age and pack-years to 20. Lung screening remains controversial for those who do not meet the updated USPSTF criteria, but who have additional risk factors for the development of lung cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Invasive Lobular Carcinoma: A Review of Imaging Modalities with Special Focus on Pathology Concordance

Invasive lobular cancer (ILC) is the second most common type of breast cancer. It is characterized by a unique growth pattern making it difficult to detect on conventional breast imaging. ILC can be multicentric, multifocal, and bilateral, with a high likelihood of incomplete excision after breast-conserving surgery. We reviewed the conventional as well as newly emerging imaging modalities for detecting and determining the extent of ILC- and compared the main advantages of MRI vs. contrast-enhanced mammogram (CEM). Our review of the literature finds that MRI and CEM clearly surpass conventional breast imaging in terms of sensitivity, specificity, ipsilateral and contralateral cancer detection, concordance, and estimation of tumor size for ILC. Both MRI and CEM have each been shown to enhance surgical outcomes in patients with newly diagnosed ILC that had one of these imaging modalities added to their preoperative workup.

Antithrombotic Therapy and Hematoma Risk during Image-guided Core-Needle Breast Biopsy

Background For image-guided core-needle breast biopsy (CNBB), it remains unclear whether antithrombotic medication should be withheld because of hematoma risk. Purpose To determine hematoma risk after CNBB in patients receiving antithrombotic medication and to stratify risk by antithrombotic type. Materials and Methods This HIPAA-compliant retrospective study included US-, stereotactic-, or MRI-guided CNBBs performed across six academic and six private practices between April 2019 and April 2021. Patients were instructed to continue antithrombotic medications, forming two groups: antithrombotic and nonantithrombotic. Hematomas were defined as new biopsy-site masses with a diameter of 2 cm or larger on postprocedure mammograms. Hematomas were considered clinically significant if management involved an intervention other than manual compression. Patient age, type of antithrombotic medication, practice type, image guidance modality, needle gauge and type, and outcome of pathologic analysis were recorded. Multivariable logistic regression analysis was used to analyze variables associated with hematomas. Results A total of 3311 biopsies were performed in 2664 patients (median age, 60 years; IQR, 48-70 years; 2658 women). The nonantithrombotic group included 2788 biopsies, and the antithrombotic group included 523 biopsies (328 low-dose aspirin, 73 full-dose antiplatelet drugs, 51 direct oral anticoagulants, 36 warfarin, 32 daily nonsteroidal anti-inflammatory drugs, three heparin or enoxaparin). The antithrombotic group had a higher overall hematoma rate (antithrombotic group: 49 of 523 biopsies [9.4%], nonantithrombotic group: 172 of 2788 biopsies [6.2%]; P = .007), but clinically significant hematoma rates were not different (antithrombotic group: two of 523 biopsies [0.4%], nonantithrombotic group: one of 2788 biopsies [0.04%]; P = .07). At multivariable analysis, age (odds ratio [OR], 1.02; 95% CI: 1.01, 1.03; P < .001), 9-gauge or larger needles (OR, 2.1; 95% CI: 1.28, 3.3; P = .003), and full-dose antiplatelet drugs (OR, 2.5; 95% CI: 1.29, 5.0; P = .007) were associated with higher hematoma rates. US guidance (OR, 0.26; 95% CI: 0.17, 0.40; P < .001) and 10-14-gauge needles (OR, 0.53; 95% CI: 0.36, 0.79; P = .002) were predictive of no hematoma. Conclusion Because clinically significant hematomas were uncommon, withholding antithrombotic medications before core-needle breast biopsy may be unnecessary. Postbiopsy hematomas were associated with full-dose antiplatelet drugs, patient age, and 9-gauge or larger needles. No association was found with other types of antithrombotic medication. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chang and Yoen in this issue.

ACR Appropriateness Criteria® Suspected Pulmonary Hypertension: 2022 Update

Pulmonary hypertension may be idiopathic or related to a large variety of diseases. Various imaging examinations may be helpful in diagnosing and determining the etiology of pulmonary hypertension. Imaging examinations discussed in this document include chest radiography, ultrasound echocardiography, ventilation/perfusion scintigraphy, CT, MRI, right heart catheterization, and pulmonary angiography. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Staging and Follow-Up of Esophageal Cancer

This document provides recommendations regarding the role of imaging in the staging and follow-up of esophageal cancer. For initial clinical staging, locoregional extent and nodal disease are typically assessed with esophagogastroduodenoscopy and esophageal ultrasound. FDG-PET/CT or CT of the chest and abdomen is usually appropriate for use in initial clinical staging as they provide additional information regarding distant nodal and metastatic disease. The detection of metastatic disease is critical in the initial evaluation of patients with esophageal cancer because it will direct patients to a treatment pathway centered on palliative radiation rather than surgery. For imaging during treatment, particularly neoadjuvant chemotherapy, FDG-PET/CT is usually appropriate, because some studies have found that it can provide information regarding primary lesion response, but more importantly it can be used to detect metastases that have developed since the induction of treatment. For patients who have completed treatment, FDG-PET/CT or CT of the chest and abdomen is usually appropriate for evaluating the presence and extent of metastases in patients with no suspected or known recurrence and in those with a suspected or known recurrence. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Role of advanced imaging with cardiac computed tomography and MRI in atrial and ventricular ablation

PURPOSE OF REVIEW

Increasing evidence supports the use of advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) in the work-up of patients with arrythmias being considered for ablation.

RECENT FINDINGS

Advances in imaging technology and postprocessing are facilitating the use of advanced imaging before, during and after ablation in patients with both atrial and ventricular arrhythmias.In atrial arrythmias, quantitative assessment of left atrial wall thickness on CCT and quantification of late gadolinium enhancement (LGE) on CMR identify patients more likely to develop recurrent atrial arrythmias following ablation. In addition, in patients with recurrent arrythmia post ablation, LGE CMR can potentially identify targets for repeat ablation.In ventricular arrythmias, qualitative assessment of LGE can aide in determining the optimal ablation approach and predicts likelihood of ventricular arrythmias inducibility. Quantitative assessment of LGE can identify conduction channels that can be targeted for ablation. On CCT, quantitative assessment of left ventricular wall thickness can demonstrate myocardial ridges associated with re-entrant circuits for ablation.

SUMMARY

This review focuses on the utility of CCT and CMR in identifying key anatomical components and arrhythmogenic substrate contributing to both atrial and ventricular arrhythmias in patients being considered for ablation. Advanced imaging has the potential to improve procedural outcomes, decrease complications and shorten procedural time.

Lessons Learned from a Delayed Diagnosis of Atrioesophageal Fistula: A Multidisciplinary Approach

Atrioesophageal fistulas are a rare complication of radiofrequency ablation that requires rapid identification and emergent surgical repair to prevent morbidity and mortality. We report a case of a 32-year-old man with atrial fibrillation presenting with chest pain followed by rapidly progressive sepsis and embolic cerebrovascular accident 23 days after radiofrequency ablation. Subtle initially overlooked findings on multiple computed tomography caused a delay in diagnosis. Atrioesophageal fistulas remain diagnostically challenging. A high index of suspicion coupled with serial computed tomography of the chest with intravenous and oral contrast reviewed by a multimodal team is essential to make a timely diagnosis. This article is protected by copyright. All rights reserved.

ACR Appropriateness Criteria® Chronic Cough

Chronic cough is defined by a duration lasting at least 8 weeks. The most common causes of chronic cough include smoking-related lung disease, upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. The etiology of chronic cough in some patients may be difficult to localize to an isolated source and is often multifactorial. The complex pathophysiology, clinical presentation, and variable manifestations of chronic cough underscore the challenges faced by clinicians in the evaluation and management of these patients. Imaging plays a role in the initial evaluation, although there is a lack of high-quality evidence guiding which modalities are useful and at what point in time the clinical evaluation should be performed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Altered pulmonary blood volume distribution as a biomarker for predicting outcomes in COVID-19 disease

INTRODUCTION

Evidence suggests that vascular inflammation and thrombosis may be important drivers of poor clinical outcomes in patients with COVID-19. We hypothesised that a significant decrease in the percentage of blood volume in vessels with a cross-sectional area between 1.25 and 5 mm2 relative to the total pulmonary blood volume (BV5%) on chest computed tomography (CT) in COVID-19 patients is predictive of adverse clinical outcomes.

METHODS

We performed a retrospective analysis of chest CT scans from 10 hospitals across two US states in 313 COVID-19-positive and 195 COVID-19-negative patients seeking acute medical care.

RESULTS

BV5% was predictive of outcomes in COVID-19 patients in a multivariate model, with a BV5% threshold below 25% associated with OR 5.58 for mortality, OR 3.20 for intubation and OR 2.54 for the composite of mortality or intubation. A model using age and BV5% had an area under the receiver operating characteristic curve of 0.85 to predict the composite of mortality or intubation in COVID-19 patients. BV5% was not predictive of clinical outcomes in patients without COVID-19.

CONCLUSIONS

The data suggest BV5% as a novel biomarker for predicting adverse outcomes in patients with COVID-19 seeking acute medical care.

Extracorporeal membrane oxygenation in acute respiratory distress syndrome due to influenza A (H1N1)pdm09 pneumonia. A single-center experience during the 2013-2014 season

Objective

This report aimed to describe the outcomes of the patients with severe H1N1 associated acute respiratory distress syndrome who were treated with extracorporeal membrane oxygenation therapy.

Methods

This retrospective review analyzed a single-center cohort of adult patients with H1N1-related acute respiratory distress syndrome who were managed with veno-venous extracorporeal membrane oxygenation during the winter of 2013/2014.

Results

A total of 10 patients received veno-venous extracorporeal membrane oxygenation for H1N1 influenza between January 2013 and March 2014. Seven patients were transferred to our center for extracorporeal membrane oxygenation consideration (all within 72 hours of initiating mechanical ventilation). The median patient age was forty years, and 30% were female. The median arterial oxygen partial pressure to fraction of inspired oxygen ratio was 62.5, and the median RESP score was 6. Three patients received inhaled nitric oxide, and four patients were proned as rescue therapy before extracorporeal membrane oxygenation was initiated. The median duration of mechanical ventilation was twenty-two days (range, 14 - 32). The median length of stay in the intensive care unit was twenty-seven days (range, 14 - 39). The median hospital length of stay was 29.1 days (range, 16.0 - 46.9). Minor bleeding complications occurred in 6 of 10 patients. Eight of the ten patients survived to hospital discharge.

Conclusion

The survivors were relatively young and discharged with good functional status (i.e., enhancing quality-adjusted life-years-saved). Our experience shows that even a relatively new extracorporeal membrane oxygenation program can play an important role in that capacity and provide excellent outcomes for the sickest patients.

Advanced Imaging of Mitral Valve Disease

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Aneurysms of the ascending aorta and arch: the role of imaging in diagnosis and surgical management

Thoracic aortic aneurysms tend to be asymptomatic and were previously often diagnosed only after a complication such as dissection or rupture occurred. Better imaging techniques and an increase in the use of cross-sectional imaging has led to an increase in the diagnosis of aortic aneurysms, which has allowed for elective treatment prior to the development of a complication. The location, size and etiology of an aneurysm all impact the clinical outcomes and these factors are used to determine the appropriate timing of surgical replacement. Surgeons often rely on the information obtained from preoperative imaging to determine when to intervene and what type of procedure will be necessary, making it important for the radiologist to understand these issues in order to provide the necessary information. Postoperative imaging after surgical replacement of the aorta is also important, as there are some common findings that occur in this patient population that can impact how they are treated. The purpose of this article is to review the etiology and associated findings of aneurysms of the ascending aorta and arch, with a focus on how computed tomography angiography and magnetic resonance angiography findings are used to determine the appropriate timing for elective replacement and the type of surgical procedure, as well as the role of follow-up imaging. This will include a review of the most commonly performed types of surgical procedures, to provide an understanding of how the findings of preoperative imaging studies impact what the surgeon does in the operating room, as well as the expected findings of postoperative imaging studies.

CT and MR imaging of the mitral valve: radiologic-pathologic correlation

Computed tomography (CT) and magnetic resonance (MR) imaging are increasingly important adjuncts to echocardiography for the evaluation of mitral valve disease. The mitral valve may be involved in various acquired or congenital conditions with resultant regurgitation or stenosis, and many of these conditions can be identified with CT or MR imaging. In addition, CT is useful for detecting and monitoring postoperative complications after mitral valve repair or replacement. As the use of CT and MR imaging increases, awareness of the CT and MR imaging appearances of the normal mitral valve and the various disease processes that affect it may foster recognition of unsuspected mitral disease in patients undergoing imaging for other purposes. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.306105518/-/DC1.

Amphetamine-induced activation of forebrain EEG is prevented by noradrenergic beta-receptor blockade in the halothane-anesthetized rat

RATIONALE

Amphetamine (AMPH)-like stimulants represent an intensively studied class of psychoactive drugs. Despite the well-known and potent arousal-enhancing effects of these drugs, the neurobiological substrates of AMPH-induced arousal have rarely been examined explicitly. Activity of the locus coeruleus-noradrenergic system is causally and positively related to behavioral and electroencephalographic (EEG) indices of arousal. For example, activation of locus coeruleus neurons or stimulation of medial basal forebrain noradrenergic beta-receptors elicits activation of forebrain EEG in the anesthetized rat. Further, stimulation of noradrenergic beta-receptors within the medial basal forebrain elicits a substantial increase in alert, active waking. These and other observations suggest that at least some of the arousal-enhancing actions of AMPH-like stimulants derive from AMPH-induced increases in noradrenergic neurotransmission at beta-receptors. The current study examines the extent to which AMPH-induced activation of cortical EEG is dependent on actions of central beta-receptors.

METHODS

The effects of intracerebroventricular (ICV; 2 microl) pretreatment with either vehicle (artificial extracellular fluid) or the beta-antagonist, timolol (25, 50 or 100 microg), on the cortical EEG activating effects of intravenous AMPH (0.15 mg/kg) were examined in the halothane-anesthetized rat. EEG was recorded on polygraph and video recording tape and later analyzed using power spectral analyses (PSA). AMPH-induced alteration in cortical EEG activity was measured using PSA in vehicle- and timolol-pretreated animals.

RESULTS

Neither vehicle nor timolol ICV infusions altered cortical EEG activity patterns. In vehicle-pretreated animals, AMPH elicited a robust activation of cortical EEG, characterized by the substantial decrease in large-amplitude, slow-wave activity. Timolol pretreatment dose-dependently prevented AMPH-induced cortical EEG activation. This effect of timolol was statistically significant at the 50 microg and 100 microg dose.

CONCLUSIONS

These observations indicate that, under these experimental conditions, AMPH-induced activation of the forebrain is dependent on actions of noradrenergic beta-receptors. Combined with previous observations, these observations support the hypothesis that AMPH-induced increases in arousal involve noradrenergic neurotransmission at beta-receptors.

Clinical efficacy of two dentin desensitizing agents

PURPOSE

To compare the clinical effect over 3 months of two commercially available desensitizing agents on the level of discomfort of patients with complaints of dentin sensitivity.

MATERIALS AND METHODS

An oxalate-containing pre-polymerized resin suspension (Pain-Free), a 0.7% fluoride solution (DentinBloc), and a distilled water placebo were compared in a clinical setting. Ten volunteer patients exhibiting three or more teeth that were sensitive to touch and to a stream of forced air were enrolled in the study (52 teeth total). Each patient's level of sensitivity to tactile stimuli and to a forced air stream was recorded using a visual analog scale (VAS). The tactile stimulus was a metal probe rubbed across the exposed dentin with a constant pressure of 40 grams. A 1-second blast of air from a dental unit air syringe was used to generate the air stream. The desensitizing agents were applied according to manufacturers' guidelines. Sensitivity measurements were recorded at baseline, immediately after treatment, at 1 week, 1 month, and at 3 months. VAS pain scores were analyzed using a repeated measures ANOVA (alpha = 0.05).

RESULTS

The pre-polymerized resin suspension (Pain-Free), the fluoride-containing solution (DentinBloc), and the placebo all decreased dentin sensitivity. No significant difference was found among the desensitizing agents at any time period (P > 0.05).

Psychological and physiological characteristics of sweet food "addiction"

OBJECTIVE

Drug addicts in general can be distinguished from nonaddicts by their affective and physiological and craving responses to drug-related cues. The purpose of this study was to examine similar affective, physiological, and behavioral variables in chocolate "addicts" and control subjects.

METHODS

Sixteen addicts and 15 control subjects took part in two laboratory experiments in which their heart rate, salivation, and self-reported responses were measured.

RESULTS

In the presence of external chocolate cues, chocolate addicts were more aroused, reported greater cravings, experienced more negative affect, and also ate more chocolate than control subjects. Self-report measures on eating attitudes and behavior, body image, and depression confirmed that a relationship exists between "chocolate addiction" and problem eating. Chocolate addicts showed more aberrant eating behaviors and attitudes than controls, and were also significantly more depressed.

DISCUSSION

Chocolate addicts may be considered to be a parallel with addicts generally, because they differ from controls in craving for chocolate, eating behavior, and psychopathology (in respect of eating and affect).

Carbohydrate removal fails to eliminate the heterogeneity of human prostatic acid phosphatase

Human prostatic acid phosphatase is known to display considerable charge heterogeneity upon isoelectric focusing. The structural basis of this heterogeneity is not known, although it has been widely attributed to variations in the nature of the carbohydrate chains or to substituents on the carbohydrate chains of the glycoprotein. In this study, the role of the carbohydrate chains in the charge heterogeneity of the protein was examined. First, sialic acid residues were removed by treatment of the acid phosphatase with neuraminidase. The desialo enzyme was fractionated and purified by L-tartramic acid affinity chromatography. Then, after the protein oligosaccharide linkages were made accessible by the presence of NP-40 or by denaturing the protein, the protein was completely deglycosylated by endo-beta-N-acetylglucosaminidase F at pH 4.5 and 9.3. Two discrete intermediates were clearly resolved by SDS gel electrophoresis during the deglycosylation of the denatured protein at pH 9.3, indicating the existence of three sites of glycosylation on the protein. Peptide mixtures were obtained by digestion of carboxymethylated and citraconylated derivatives of the enzyme with trypsin and the glycopeptides were isolated. The amino acid compositions of the glycopeptides were consistent with the interpretation that there are a minimum of two sites of glycosylation on each peptide subunit of the enzyme. Isoelectric focusing experiments on the native, desialo, and denatured, deglycoso acid phosphatase showed that the heterogeneity of the protein is not eliminated either by desialylation or by deglycosylation. Thus, the electrophoretic heterogeneity of human prostatic acid phosphatase does not lie primarily in the oligosaccharide part of the glycoprotein or in altered conformational states of the protein, but in structural variations of the polypeptide itself. The heterogeneity may be due to variations at the C-terminus, partial deamidation, phosphorylation, sulfation or other posttranslational modifications of the protein chain.

Kiviat graphs

Once in a very great while an idea comes along that quickly captures many imaginations. The circular graphic technique proposed nearly two years ago by Phil Kiviat, our illustrious Chairman, and very appropriately named "Kiviat Graphs" by our erst-while (and sorely missed) "Software Empiricist," Ken Kolence, is one of these ideas.