Assessment of aortic regurgitation mechanism with cardiac magnetic resonance: an echocardiography comparative study

Funding Acknowledgements

Type of funding sources: None.

Background

Aortic regurgitation (AR) quantification still remains challenging and requires an integrated approach. AR mechanism is one key parameter to take into account to assess its severity and repairability, and thus help to guide surgical decision. Although Cardiac Magnetic Resonance (CMR) has a growing interest in AR quantification, its performance to identify aortic AR mechanism has never been studied.

Purpose

We intended to define CMR Performance in this setting, by using echocardiography as reference.

Methods

AR mechanism was systematically evaluated in sixty-seven patients (81% male, mean age 46 ± 20 years) with chronic AR using CMR, and compared to transthoracic (TTE) and transesophageal (TEE) echocardiography as gold standard. AR were categorized as follows: type 1, aortic dilatation; type 2, Cusp prolapse; type 3, restrictive cusp motion. Jet direction, number of cusps and calcification (1 = no calcification, 2 = spots, 3 = big calcification interfering with cusp motion and 4 = Extensive with restricted cusp motion) were also evaluated.

Results

At TTE/TEE, mechanisms of AR were type 1 in 56 (83.5%), type 2 in 33 (49.2%), type 3 in 24 (35%). Agreement between TTE/TEE and CMR was modest, with respectively 74.6% (k= 0.4), 79.1% (k = 0.58) and 74.6% (k = 0.44). Bicuspid aortic valve was found in 44 (65.7%) patients at TTE/TEE, agreement with CMR was excellent, 98.5% (k = 0.97).  Jet was directed to the mitral valve in 42 (62.7%), at the inter ventricular septum in 12 (17.9%), and central in 13 (19.4%). Agreement with CMR was correct, respectively 80% (k = 0,6), 88% (k = 0.62) and 83.5% (K= 0.52). Calcification extension was 1 in 26 (38.8%), 2 in 25 (37.3%), 3 in 11 (16.4%) and 4 in 5 (7.5%). Agreement with CMR was poor, 44.7% (K= 0.28).

Conclusion

Accuracy between CMR and TTE/TEE to evaluate chronic AR mechanism and repairability was modest, with lower performance to define calcification extension.

Abstract Figure. AR classification TTE/TEE vs CMR

Utility of 3-dimensional transoesophageal echocardiography for mitral annular sizing in transcatheter mitral valve replacement procedures: a cardiac computed tomography comparative study

Funding Acknowledgements

Type of funding sources: None.

Background.  3-dimensional transoesophageal echocardiography (3D-TEE) is frequently used as an initial screening tool in the evaluation of patients who are candidates to Transcatheter Mitral Valve Replacement (TMVR). However, little is known about the imaging correlation with the gold-standard computed tomography (CT) imaging. We aimed at testing the quantitative differences between these two modalities and finding the best 3D-TEE parameters for TMVR screening.

Methods. We included 57 patients referred to our Heart Valve Clinic for TMVR with prostheses specifically designed for the mitral valve. Mitral annulus (MA) analyses were performed using commercially available software in 3D-TEE and CT.

Results. 3D-TEE was feasible in 52 patients (91%). Although 3D-TEE measurements were slightly lower than in CT, both measurements of projected MA area and perimeter showed excellent correlation with small differences between the two modalities (r = 0.88 and r = 0.92 respectively, p < 0.0001). Correlations were significant but lower for MA diameters (r = 0.68 to 0.72, p < 0.0001) and mitro-aortic angle (r = 0.53, p = 0.0001). ROC curve analyses showed that 3D-TEE had a good ability to predict TMVR screening success defined by constructors based on CT measurements with a range of 12.9 to 15cm² for MA area (AUC = 0.88-0.91, p < 0.0001), 128 to 139mm for MA perimeter (AUC = 0.85-0.91, p < 0.0001), 35 to 39mm for anteroposterior diameter (AUC = 0.79-0.84 p < 0.0001) and 37 to 42mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, p < 0.0001) (Figure 1). Conclusion. 3D-TEE measurements of MA dimensions display strong correlation with CT measurements in patients undergoing TMVR screening process. 3D-TEE should be proposed as a reasonable alternative to CT in this vulnerable population.

Abstract Figure.

Single-centre prospective comparison between contrast-enhanced ultrasound and computed tomography angiography after EVAR

AIM

To evaluate contrast-enhanced ultrasound (CEUS) as an effective alternative to CT-angiography (CTA) for endoleak detection and aneurismal sac diameter measurement in the follow-up after endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

From January 2006 to December 2010, 395 patients underwent EVAR follow-up with both CTA and CEUS. The diameter of the aneurismal sac and the presence of endoleaks were evaluated in all the 395 paired examinations.

RESULTS

Bland-Altman plots showed a good agreement in aneurismal sac diameter evaluation between the two imaging modalities. The mean diameter was 54.93 mm (standard deviation (SD) ±12.57) with CEUS and 56.01 mm (SD ± 13.23) with CTA. The mean difference in aneurismal sac diameter was -1.08 mm ± 3.3543 (95% confidence interval (CI), -0.75 to -1.41), in favour of CTA. The number of observed agreement in endoleak detection was 359/395 (90.89%). The two modalities detected the same type I and type III endoleaks. McNemar's χ(2) test confirmed that CTA and CEUS are equivalent in endoleak detection.

CONCLUSIONS

CEUS demonstrated to be as accurate as CTA in endoleak detection and abdominal aortic aneurysm diameter measurements during EVAR follow-up, without carrying the risks of radiation exposure or nephrotoxicity. Even if it cannot be proposed as the sole imaging modality during follow-up, our analysis suggests that it should have a major role.

[Idiopathic vasospastic angiopathy of the internal carotid arteries: A rarely recognized cause of ischemic stroke in young individuals]

INTRODUCTION

Idiopathic vasospastic angiopathy of the internal carotid arteries is a rare and largely unknown cause of ischemic stroke.

METHODS

We report the case of a 39-year-old man with migraine treated by beta-blockers, who had been suffering from progressive right visual impairment and headache for one week. He then experienced a seizure and left hemiparesis. Ophthalmological examination revealed right retinal ischemia and partial left homonymous hemianopia. MRI revealed a long stenosis of both carotid arteries and a recent ischemic stroke in the territory of the right middle cerebral artery. The diagnosis of vasospastic angiopathy of the internal carotid arteries was made based on a second MRI and colored duplex sonography which showed a decrease in the stenosis and no intraparietal hematoma confirming the vasospasm mechanism for stenosis. The clinical course was favorable with calcium channel blockers and aspirin. Use of vasoconstrictor treatments was contraindicated.

DISCUSSION/CONCLUSION

Idiopathic vasospastic angiopathy of the internal carotid arteries has been rarely documented. Association with migraine has been mentioned but remains unclear in the literature. This etiology for stroke is probably under-diagnosed due to lack of rapid and repeated examinations of the cervical arteries (angio-MR and colored duplex sonography) to confirm the vasospasm mechanism. Recurrences have been reported justifying a specific secondary preventive treatment to induce vasodilatation. Vasoconstrictor treatments should be contraindicated.

Méningiome du nerf optique. L’expérience lyonnaise

Meningioma is an unfrequent optic nerve tumor. Clinical symptoms are not specific, and pathology exam not easily accessible. The diagnosis is usually based on imaging findings. We report our experience, based on twenty patients. Most of them were middle-aged women (mean age=47 years old). The optic nerve meningioma (ONM) was often revealed by visual dysfunction. Ophthalmological evaluation was altered in most patients (visual acuity, visual fields, fundi). The gold-standard exam was MRI of the optic nerve, with and without gadolinium, and with fat-sat sequences. Thirty percent of the lesions remain stable without treatment. Functional prognosis has been improved only by conformal fractionated radiotherapy, but indications and modalities remain to be specified.

Hyperthyroidism and Cerebral Venous Thrombosis

The demonstration of an underlying prothrombotic condition in cerebral venous thrombosis (CVT) may have important practical consequences in terms of prevention. Thyrotoxicosis through a hypercoagulable state may be a predisposing factor for CVT. The authors present the cases of 4 patients who developed CVT and hyperthyroidism. At the acute stage, hyperthyroidism was associated with an increase in factor VIII (FVIII). At follow-up, FVIII level remained increased in 2 patients. Hyperthyroidism may have an impact on FVIII level. Accordingly in patients with hyperthyroidism and neurological symptoms, the diagnosis of CVT should be considered and an exhaustive coagulation screening may be appropriate.

Tobacco smoking by pregnant women. Disturbances in metabolism of branched chain amino acids and fetal growth

Pregnancy alone lowered the plasma AA concentrations of ileu, leu, and val when compared to their concentrations in nonpregnant nonsmokers. Plasma concentrations of val, ileu, and leu were significantly higher in pregnant smokers than in pregnant nonsmokers. Therefore, the utilization of BCAA was more reduced in pregnant smokers than that which could be predicted from plasma AA concentrations of nonpregnant nonsmokers.

African Burkitt's lymphoma in the Cape province of South Africa and in Namibia

The clinical features, incidence and pattern of jaw involvement, and seasonal occurrence in relation to 22 patients with Burkitt's lymphoma in the Cape province and Southwest Africa were analyzed. The mean age, male dominance, and pattern of organ involvement paralleled typical African Burkitt's lymphoma. Development of the patients' disease was more likely during the rainy season. The frequency and pattern of jaw involvement resembled typical African Burkitt's lymphoma. The frequency of jaw involvement was similar in white and nonwhite patients. Members of all racial groups had typical African Burkitt's lymphoma.

Effect of preeclampsia on carboxyhemoglobin levels: a mechanism for a decrease in P50

COHb levels were measured in 15 preeclamptic pregnant women and 15 normal pregnant women to investigate the cause for the decrease in P50 associated with preeclampsia. The authors also included six normal and six preeclamptic pregnant patients from the above groups in the determination of P50. Measurements of COHb levels were performed in a Radiometer OSM2 Hemoximeter. Determination of P50 was done using an IL 237 Tonometer, a Radiometer, OSM2 Hemoximeter, and a Corning 168 pH/Blood Gas Analyzer. Preeclamptic pregnant patients had a mean COHb level of 2.8%, whereas normal pregnant women had a mean COHb level of 0.7% (P less than 0.001). Preeclamptic patients also had a significantly lower (24.4 mmHg) P50 than normal pregnant women (P50 = 30.1 mmHg) (P less than 0.001). The authors conclude that a significant elevation of COHb in preeclamptic pregnant women is partly responsible for a significant decrease in P50 seen in preeclampsia.

Effect of pre-eclampsia on plasma cholinesterase activity

Plasma cholinesterase (PCHE) activity was determined using a colorimetric method in 11 healthy non-pregnant women, 11 healthy pregnant women at term, and 11 pre-eclamptic pregnant women at term. The mean plasma cholinesterase activities for healthy non-pregnant women, healthy pregnant women and pre-eclamptic pregnant women were 438 +/- 81,257 +/- 25 and 173 +/- 18 units . ml-1, respectively. Our data suggest that there is a significant reduction in plasma cholinesterase activity in preeclamptic pregnant women when compared to healthy non-pregnant (p less than 0.001) and healthy pregnant women (p less than 0.001).

Type I histiocytosis X presenting as biliary atresia. A case report

Histiocytosis X may present in a variety of ways. We report a patient who presented with the unusual feature of infiltration of the hepatic duct with histiocytes, manifesting as biliary atresia.