Predictive value of Cardiac Magnetic Resonance: new and old parameters in the natural history of repaired Tetralogy of Fallot

BACKGROUND

Patients with repaired Tetralogy of Fallot (rTOF) often develop pulmonary regurgitation (PR) and right ventricle (RV) dysfunction, experiencing increased mortality and morbidity rates in adulthood. Pulmonary valve replacement (PVR) timing to address PR is controversial. Cardiac Magnetic Resonance (CMR) is the gold standard for morpho-functional evaluation of complex cardiopathies. This study aims to identify CMR parameters predictive of adverse outcomes to help defining the best therapeutic management of rTOF patients.

METHODS

130 rTOF patients who underwent CMR (2006-2019) were enrolled in this retrospective single-center study. CMR, clinical, ECG and exercise data were analyzed. Univariate and multivariate analyses identified clinical and CMR parameters predictive of adverse outcomes both individually (e.g., death, arrhythmias, heart failure (HF), pharmacological therapy, QRS ≥ 160ms) and as composite outcome.

RESULTS

Univariate analysis confirmed RV volumes and RV ejection fraction corrected for PR as adverse outcome predictors and identified interesting correlations: pulmonary artery bifurcation geometry and abnormal interventricular septum (IVS) motion with arrhythmias (p < .001; p = .037), HF (p = .049; p = .005), composite outcome (p = .039; p = .009); right atrium (RA) dimensions with the composite outcome and the outcomes individually (p < .001). The best predictive models by multivariate analysis included sex (male), RV and RA dilation for QRS ≥ 160ms, time form repair to CMR, age at TOF repair and IVS fibrosis for pharmacological therapy.

CONCLUSIONS

Besides RV volumes, new adverse prognostic factors could guide rTOF therapeutic management: pulmonary arteries morphology, abnormal IVS motion, RV dysfunction, RA dilation. Perspective multicentric evaluation is needed to specify their effective role.

Different aortic valve calcium scores by computed tomography scan in patients with severe aortic stenosis and concomitant cardiac amyloidosis

Background

The coexistence of cardiac amyloidosis (CA) and degenerative aortic stenosis (AS) is increasing but the diagnosis is challenging because these two conditions share a common echocardiographic phenotype (1). Different predictors have been proposed in the last few years, including clinical, ECG-graphic and echocardiographic features (2–3).

Purpose

To identify a new marker of concomitant CA in patients with severe AS analyzing computed tomography scan (CT).

Methods

55 patients with severe AS and suspicion of concomitant CA were retrospectively enrolled. Patients with a bicuspid aortic valve, previous aortic valve replacement, or an incomplete diagnostic workup for CA were excluded. 33 patients underwent CT-scan and were included in the final analysis.

Results

None of the patients presented laboratory suspicion for AL amyloidosis; 12 patients (AS-CA) had positive 99m Tc-DPD bone scintigraphy (two with visual score 1, eight score 2 and two score 3), 21 patients (AS-alone) had negative bone scintigraphy. AS-CA patients had a median age of 85,5 years (versus 81,5) with only one female patient (versus 8 in the AS-alone group). AVA indexed were comparable between AS-CA and AS-alone groups (0,4 versus 0, 3 mm2/m2, p: 0.25). Stroke volume evaluated by pulsed Doppler, maximum and mean gradient were significatively lower in AS-CA group (respectively 30 versus 41 ml/m2, p: 0.017, 62 versus 74 mmHg, 0.038 and 33 versus 46 mmHg, p:0.022) with a higher percentage of low flow-low gradient aortic stenosis in AS-CA group (7 patients, 58% vs 3 patients in AS-alone 14%, p: 0.027), in line with the literature. ECG at first presentation in AS-CA group showed atrial fibrillation in 8 patients (67%), versus 2 patients in the AS-alone group (10%), and lower QRS voltages (peripheral QRS score 40 mV vs 51 mV, p-value:0.017; total QRS score 113 mV versus 155 mV, p-value: 0.005). The echocardiogram showed a more thickened IVS and PW in AS-CA patients (17 versus 15 mm, p: 0.05 and 15 versus 14 mm, p: 0.013), an augmented left ventricular mass (441 versus 356 g, p: 0.036) with a decreases longitudinal systolic function (septal S wave at TDI 4.4 versus 5.2 cm/s, p: 0.026, lateral S wave 4.1 versus 5.6 cm/s, p: 0.024) and a reduction in myocardial contraction fraction (12 versus 14%, p: 0.036).

CT- aortic valve calcium was quantified by an experienced operator. A statistically significant difference between AS-CA and AS-alone groups was observed in calcium score (3345 versus 4785 Hounsfield units, p: 0.037) calcium volume (2411 versus 3626 mm2, p: 0.03) and calcium mass (687 versus 1147 g, p: 0.023)

Conclusions

This study is the first to our knowledge to use relative aortic valve calcium score evaluation from CT imaging to characterize patients with severe AS with or without concomitant CA in addition to the classical clinical, ECG graphic, echocardiographic parameters. CT-aortic valve calcium burner was significatively lower in patients with concomitant CA.

Funding Acknowledgement

Type of funding sources: None. CT scan and bone scintigraphy

Prognostic value of pulmonary artery diameter in patients with pulmonary arterial hypertension

Background

Pulmonary artery (PA) dilation is common in pulmonary arterial hypertension (PAH) and may cause left main coronary artery (LMCA) compression. This complication have been sistematically evaluated in patients with angina but no evidence is available for patients asymptomatic for angina.

Purpose

To evaluate the prognostic value of PA diameter and the prevalence of LMCA compression in PAH patients with and without angina.

Methods

All patients with PAH and a baseline angio-CT scan were included. The last angio-CT scan performed was considered for PA diameter increase velocity calculation. Patients with angina or radiological signs of suspected LMCA compression underwent a coronary (cor)-CT scan. Patients with a not negative cor-CT underwent invasive coronary angiography. If clinically indicated invasive coronary angiography was performed without a preliminary cor-CT. To evaluate the predictivity for compression at coronary angiography the PA diameter at cor-CT or at the nearest angio-CT scan was considered.

Results

958 patients were included. PA diameter at baseline is higher in patients with congenital heart disease (CHD) and is not predictive of death. The velocity of PA diameter increase is lower in patients with connective tissue disease and is a risk factor for death in both overall population and different etiological subgroups except CHD and pulmonary veno-occlusive disease. 180 patients had angina and 50 had LMCA compression. 120 patients without angina underwent cor-CT and/or coronary angiography and 15 patients had LMCA compression. The best PA diameter cut-offs predicting LMCA compression in symptomatic/asymptomatic patients were, respectively, 40/42 mm (sensitivity and specificity, respectively, 80 and 72%/87 and 77%).

Conclusion

28% of patients with angina and 13% of patients without angina had LMCA compression. We found a similar PA diameter predicting LMCA compression in patients with or without angina. PA diameter, instead, was not predictive of prognosis (maybe because most deaths were related to heart failure and also because patients with LMCA compression were treated with stenting, possibly preventing sudden cardiac death). Eventually, PA diameter velocity increase is associated with prognosis but this may only reflect a severe disease refractory to medical therapy.

Funding Acknowledgement

Type of funding source: None

Open surgery versus TEVAR in complicated type B acute aortic syndromes: outcomes of a single referral center

Background

While patients with uncomplicated acute Type B aortic syndromes (ATBAS) are usually managed with optimal medical therapy, complicated ATBAS require a quick intervention to prevent life-threatening complications. If anatomical features are favorable, TEVAR is the preferred treatment option. Nevertheless, open surgery still plays a significant role in selected cases. The optimal approach to complicated ATBAS remains matter of debate.

Purpose

We retrospectively evaluated our seventeen-years' experience as regional referral center for acute aortic syndromes to analyze the outcomes of TEVAR and open surgery in cases of complicated ATBAS.

Methods

Between January 2000 and December 2016, 199 patients with ATBAS were referred to our hospital: 133 aortic dissections, 53 intramural hematomas, 13 penetrating ulcers. All patients were evaluated by a multidisciplinary aortic team. 113 patients (56.8%) received the optimal medical therapy being uncomplicated, while 86 (43.2%) patients admitted with or developing a complicated form of ATBAS underwent TEVAR or open surgery during the same hospital admission. Open surgical repair was performed in cases of unsuitable anatomy for TEVAR, retrograde involvement of the arch, ascending aorta ectasia or aneurysm. In-hospital outcomes, long term survival and freedom from reoperation were analyzed and compared between the groups.

Results

No differences were observed in terms of in-hospital mortality between uncomplicated and complicated ATBAS (13.3% versus 14.0% respectively [p=0.890]). Complicated ATBAS were treated for unstable anatomical evolution (34 patients), refractory pain or uncontrollable hypertension (19 patients), visceral or peripheral malperfusion (18 patients) or impending rupture in 15 patients. Sixty-eight patients (79%) underwent TEVAR while 18 underwent open surgery (16 frozen elephant trunk [FET] and 2 descending thoracic aorta replacement). Operative timing from the onset of symptoms did not differ between two groups (9+10 (TEVAR) versus 14+16 (Open) days [p=0.233]). In-hospital mortality was 13.2% in TEVAR group versus 16.7% in open surgery (p=0.709). Postoperative myocardial infarction, visceral and peripheral ischemia and neurological outcomes were similar in two groups (p&gt;0.05), but acute kidney injury was higher in open surgery cohort (p=0.027). One, 5 and 10-years survival of uncomplicated ATBAS (medical therapy) were 75%, 58%, 34% vs. 76%, 65%, 58% in TEVAR and 83%, 76%, 76% in open surgery groups (Log rank p=0.329). Comparing TEVAR and open surgery, freedom from endovascular reoperation at 1 and 5 years was 86%, 78% vs. 66%, 60% respectively (Log rank p=0.091).

Conclusions

Surgical treatment options (open and TEVAR) modify the natural history of complicated acute type B aortic syndromes. Open surgery represents a good option in selected cases with in-hospital and long-term survival at least comparable to TEVAR.

Funding Acknowledgement

Type of funding source: None

Diagnostic accuracy of cardiac computed tomography and 18F-fluorodeoxyglucose with positron emission tomography/computed tomography in cardiac masses

Background

Understanding the nature of cardiac masses represents a challenge for clinicians in order to select the appropriate therapeutic strategies. The diagnostic accuracy of cardiac computed tomography (CT) and 18F-fluorodeoxyglucose (18F-FDG) with positron emission tomography/CT (PET/CT) in identifying the nature of cardiac masses has not been evaluated before in a large population.

Purpose

To assess the diagnostic value of CT and 18F-FDG PET/CT in defining the nature of cardiac masses, integrating morphologic features and metabolic activity.

Methods

Out of 223 we selected a final cohort 60 patients which underwent cardiac CT scan and 18F-FDG PET/CT. All masses had histological certain, apart from thrombi, in which was defined radiologic resolution after adequate anticoagulant treatment. For each mass, eight morphologic CT signs and standardized uptake value (SUVmax, SUVmean), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) in 18F-FDG PET, were evaluated.

Results

Twenty patients had benign cardiac masses and 40 patients malignant cardiac masses. Irregular tumour margins, pericardial effusion, invasions, solid nature of the mass, mass diameter, TC contrast up-take and pre-contrast characteristics were strongly associated with the malignant nature of cardiac masses (p&lt;0.001). Additionally, the presence of at least four CT signs was able to discriminate malignancies, withsensitivity of 95% and specificity of 95% (AUC=0.988, 95% CI 0.969–1). The mean value of SUVmax, SUVmean, MTV and TLG was significantly higher in malignant cardiac masses than in benign lesions (p&lt;0.001). ROC curve for diagnostic accuracy of 18F-FDG PET/CT parameters in detecting malignant lesions showed an excellent performance of SUV (AUC=0.948, 95% CI 0.891–1), MTV (AUC=0.928, 95% CI 0.841–1) and TLG (AUC=0.961, 95% CI 0.902–1).

Conclusions

In patients with cardiac masses, cardiac computed tomography and 18F-FDG PET/CT findings provide independent and incremental prognostic information regarding their nature. A systematic use of CT and 18F-FDG PET/CT is therefore useful for diagnostic and therapeutic purposes.

PET-CT evaluation of cardiac masses

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): S. Orsola Malpighi Hospital, University of Bologna

P642 Coronary arteriovenous fistulas

Clinical case

A 53 years woman in good health and un uneventful clinical history except for a mild hypercholesteremia was evaluated for palpitations. At the clinical examination she had a systolic murmur 3/6 Levine, with no signs of heart failure.

The ECG showed normal sinus rhythm with a normal heart rate (62bpm), normal atrio-ventricular and intraventricular conduction and normal repolarisation, one supraventricular premature beat. The echocardiography showed normal biventricular dimension and function, no valvular heart diseases, no septal defects, regular aortic dimensions. A giant right coronary was evidenced (Figure, panel a) with an arteriovenous fistula originating from the right coronary artery and draining through the coronary sinus into the right atrium (Figure, panel b). The CT coronary angiogram evidenced an dilated right coronary artery communicating with the coronary sinus (arteriovenous fistula) draining into the right atrium. A smaller arteriovenous fistula was evidenced between the circumflex artery (slightly dilated) and the great cardiac vein. (Figure, panel c-e)

The Treadmill test didn’t evidence an induced ischemia; however the patient didn’t perform a maximal exercise (double product 20400mmHb*bpm). Moreover, during the first steps of recovery frequent supraventricular premature beats were registered with phases of bigeminies followed by a junctional rhythm phase. Thus, a Gated myocardial Perfusion SPECT was performed evidenced a mild stress induced ischemia of the inferolateral and apical left ventricle wall with normal rest perfusion and normal left ventricle volumes (125ml during exercise and 134ml at rest) with a normal ejection fraction ( &gt; 65%). (Figure, panel f)An elective coronarography was planned. The patient is on therapy with beta-blockers and aspirin. The patient is asymptomatic for angina. Antibiotic prophylaxis was recommended for dental, gastrointestinal, or urologic procedures. Discussion: Coronary arteriovenous fistula (CAVF), first described in 1865 by Krausein (1), are a rare congenital heart disease representing less than 0.5% of all congenital heart diseases with an extremely rare prevalence 0.002% in the general population (2). Moreover, therapy of CAVF is still controversial with previous data showing a relatively high rate of myocardial infarction after surgical repair (3). The recent AHA/ACC guideline for the management of adults with Congenital heart disease recommend a review by a knowledgeable team that may include congenital or noncongenital cardiologists and surgeons to determine the role of medical therapy and/or percutaneous or surgical closure (4) Conclusion: CAVF is a very rare congenital heart defect and might be asymptomatic and evidenced by hazard in adults patients. Therapy strategy demands a multidisciplinary team evaluation and should be be individualized according to the clinic presentation, the presence or absence of myocardial ischemia or ventricular dysfunction.

Abstract P642 Figure.

Anti-GD2-like IgM autoreactivity in multiple sclerosis patients

Seric IgM autoreactivity in 100 multiple sclerosis (MS) and 106 control (70 of whom had other neurological diseases) patients was assessed either by immunohistochemistry on normal human CNS tissue or to GD2, GD1a, GD3 by ELISA and thin layer chromatography (TLC) techniques. By double immunohistochemistry, we found that 44% of the total MS population showed seric IgM reactivity to oligodendrocytes and myelin, this finding being particularly frequent in patients with secondary progressive MS. In the non-MS cohort, positive signals were seen only in one patient. In all cases, extraction of lipids from CNS sections abolished the immunoreactivity. Among the gangliosides investigated by ELISA, anti-GD2-like IgM autoantibodies were detected in the serum of 30% of MS patients, a subgroup of whom (below 10%) reacted also with GD1a and/or GD3. More than 85% of MS cases with anti-GD2-like IgM immunoreactivity by ELISA showed also IgM anti-oligodendrocyte/myelin staining by immunohistochemistry. However, no immunostaining in MS sera was observed when gangliosides were resolved by TLC. A positive correlation with neurological disability was observed, as the Expanded Disability Status Scale of MS patients with anti-GD2-like IgM autoreactivity by ELISA was significantly worse than seronegative MS cases. The results of the present study enforce the role of glycolipids as potential autoantigens and of IgM autoantibodies in MS pathogenesis.

[Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.

A unique antibody gene signature is prevalent in the central nervous system of patients with multiple sclerosis

B cells isolated from the CSF of patients with multiple sclerosis (MS) have a unique accumulation of somatic hypermutation within the B cell receptor, termed the antibody gene signature (AGS). The focus of this study was to investigate whether the AGS could also be detected in MS brain tissue. Genetic analysis of B cells isolated from post-mortem CNS tissue samples from four MS brains demonstrated that signature enriched B cells are present at the site of tissue injury as well as in the circulating CSF.

Endovascular approach for acute aortic syndrome

Acute aortic syndrome (AAS) refers to the spectrum of aortic emergencies that include aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. These aortic pathologies may lead to aortic rupture and a timely treatment is crucial to obtain clinical success and benefit on survival. Endovascular strategies have gained wide acceptance in the management of AAS and currently represent the new minimally invasive alternative to traditional surgery. In particular in acute complicated aortic dissection endovascular therapy demonstrated a better survival and limited complications with respect to open surgery. Aim of the present study was to provide an overview of AAS and to assess the current role of endovascular aortic repair in its treatment.

Anti-myelin antibodies modulate clinical expression of childhood multiple sclerosis

Anti-myelin basic protein (MBP) antibodies in pediatric-onset MS and controls were characterized. Serum samples were obtained from 94 children with MS and 106 controls. Paired CSF and serum were obtained from 25 children with MS at time of their initial episode of acute demyelinating syndrome (ADS). Complementary assays were applied across samples to evaluate the presence, and the physical binding properties, of anti-MBP antibodies. While the prevalence and titers of serum anti-MBP antibodies against both immature and mature forms of MBP were similar in children with MS and in controls, binding characteristics and formal Surface Plasmon Resonance (SPR) studies indicated surprisingly high binding affinities of all pediatric anti-MBP antibodies. Serum levels of anti-MBP antibodies correlated significantly with their CSF levels, and their presence in children with MS was associated with significantly increased risk of an acute disseminated encephalomyelitis-like initial clinical presentation. While antibodies to both immature and mature forms of MBP can be present as part of the normal pediatric humoral repertoire, these anti-myelin antibodies are of surprisingly high affinity, can access the CNS during inflammation, and have the capacity to modulate disease expression. Our findings identify an immune mechanism that could contribute to the observed heterogeneity in spectrum of clinical presentations in early-onset MS.

Clinical value of multidetector CT coronary angiography as a preoperative screening test before non-coronary cardiac surgery

OBJECTIVE

Myocardial scintigraphy and/or conventional angiography (CA) are often performed before cardiac surgery in an attempt to identify unsuspected coronary artery disease which might result in significant cardiac morbidity and mortality. Multidetector CT coronary angiography (MDCTCA) has a recognised high negative predictive value and may provide a non-invasive alternative in this subset of patients. The aim of this study was to evaluate the clinical value of MDCTCA as a preoperative screening test in candidates for non-coronary cardiac surgery.

METHODS

132 patients underwent MDCTCA (Somatom Sensation 16 Cardiac, Siemens) in the assessment of the cardiac risk profile before surgery. Coronary arteries were screened for > or = 50% stenosis. Patients without significant stenosis (Group 1) underwent surgery without any adjunctive screening tests while all patients with coronary lesions > or = 50% at MDCTCA (Group 2) underwent CA.

RESULTS

16 patients (12.1%) were excluded due to poor image quality. 72 patients without significant coronary stenosis at MDCTCA were submitted to surgery. 30 out of 36 patients with significant (> or = 50%) coronary stenosis at MDCTCA and CA underwent adjunctive bypass surgery or coronary angioplasty. In 8 patients, MDCTCA overestimated the severity of the coronary lesions (> 50% MDCTCA, < 50% CA). No severe cardiovascular perioperative events such as myocardial ischaemia, myocardial infarction or cardiac failure occurred in any patient in Group 1.

CONCLUSIONS

MDCTCA seems to be effective as a preoperative screening test prior to non-coronary cardiac surgery. In this era of cost containment and optimal care of patients, MDCTCA is able to provide coronary vessel and ventricular function evaluation and may become the method of choice for the assessment of a cardiovascular risk profile prior to major surgery.

Evolving concepts in the treatment of traumatic aortic injury. A review article

Traumatic aortic injury (TAI) has long been considered a surgical emergency, despite the high mortality and morbidity rates in traumatized patients submitted to open surgery. Initial medical management until stabilization of associated traumatic lesions has long been a matter of debate because of the inherent risk of rupture in some of these cases. Endovascular techniques in the management of polytraumatized patients provides an additional low-invasive treatment option. Because of its lower invasiveness, without thoracotomy or the use of heparin, endovascular repair can be performed in acute patients, without the risk of destabilizing pulmonary, head or abdominal traumatic lesions. Following the publication of early small series and case reports, endovascular repair has become a widely accepted method for treating both acute and chronic traumatic lesions. Our series comprised 51 TAI patients submitted to endovascular aneurysm repair from July 1997 to December 2006, of which 24 had chronic post-traumatic aneurysms and 27 were treated in the acute or subacute phase after the traumatic event. No mortality occurred; aneurysm sealing was consistently good. Major complications included a cerebellar stroke in 1 patient due to occlusion of the left subclavian artery. No failure of aortic procedure, mortality or complications were observed during the follow-up period. Should long-term follow-up in larger series show substantial durability of the graft material, endovascular treatment will become the management of choice for TAIs.

Role and effectiveness of cardiovascular magnetic resonance in the diagnosis, preoperative evaluation and follow-up of patients with congenital heart diseases

The substantial advances in the medical and surgical treatment of congenital heart diseases have dramatically improved patients' life expectancy, as well as increased the number of those needing lifelong monitoring to identify complications and residual defects. Magnetic resonance imaging (MRI) is an ideal imaging modality for the follow-up of these young patients owing to its noninvasiveness, high reproducibility and morphological and functional accuracy. This paper describes the most appropriate MRI techniques and sequences for the study of cardiovascular heart diseases on the basis of an analysis of MRI studies carried out between January 2003 and June 2006 on 274 patients affected by all of the main congenital cardiovascular malformations, as well as a review of the literature. The advantages of MRI with respect to other imaging techniques, the problems encountered and the main clinical applications and indications of MRI, with special reference to the most common disease entities, are then discussed to define the role, the utility and the future perspectives of this imaging technique in the study of congenital heart diseases.

Interventional techniques in the treatment of aortic dissection

Acute aortic dissection continues to be one of the most catastrophic cardiovascular events. While there is a general consensus on immediate surgical repair when the ascending aorta is involved, the optimal treatment strategy for type B aortic dissection (B-AD) remains controversial. Recently, endovascular treatment with percutaneous stent-graft implantation, originally used for aortic aneurysm exclusion, has acquired an important role in the treatment of B-AD. Imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and angiography have a fundamental role in the search for the anatomic details necessary to tailor the stent graft and in evaluating the most suitable anatomy for stent graft. Transesophageal echocardiography is fundamental during the procedure to monitor the correct release of the stent graft and evaluate the result of the procedure expressed by immediate thrombosis out of the stent-graft. Again, imaging techniques, more notably CT, have a fundamental role in the postoperative followup after stent-graft placement. The risk of endoleaks may compromise the result of endovascular repair and increase the risk of aortic rupture. Several reports and a few trials attesting to technical feasibility and safety of stent-graft implantation procedures for B-AD have been reported so far. Also, a randomised trial comparing type B aortic stent-graft placement with medical therapy is currently underway. According to the investigators, new therapeutic indications are likely to emerge also in uncomplicated B-AD.

Initial screening transferrin saturation values, serum ferritin concentrations, and HFE genotypes in Native Americans and whites in the Hemochromatosis and Iron Overload Screening Study

We compared initial screening transferrin saturation (TfSat) and serum ferritin (SF) phenotypes and HFE C282Y and H63D genotypes of 645 Native American and 43,453 white Hemochromatosis and Iron Overload Screening Study participants who did not report a previous diagnosis of hemochromatosis or iron overload. Elevated measurements were defined as TfSat >50% in men and >45% in women and SF >300 ng/ml in men and >200 ng/ml in women. Mean TfSat was 31% in Native American men and 32% in white men (p = 0.0337) and 25% in Native American women and 27% in white women (p < 0.0001). Mean SF was 153 microg/l in Native American and 151 microg/l in white men (p = 0.8256); mean SF was 55 microg/l in Native American women and 63 microg/l in white women (p = 0.0015). The C282Y allele frequency was 0.0340 in Native Americans and 0.0683 in whites (p < 0.0001). The H63D allele frequency was 0.1150 in Native Americans and 0.1532 in whites (p = 0.0001). We conclude that the screening TfSat and SF phenotypes of Native Americans are similar to those of whites. The allele frequencies of HFE C282Y and H63D are significantly lower in Native Americans than in whites.

Non-invasive evaluation of the myocardial substrate of cardiac amyloidosis by gadolinium cardiac magnetic resonance

OBJECTIVE

To investigate the prevalence and distribution of gadolinium (Gd) enhancement at cardiac magnetic resonance (CMR) imaging in patients with cardiac amyloidosis (CA) and to look for associations with clinical, morphological, and functional features.

PATIENTS AND DESIGN

21 patients with definitely diagnosed CA (nine with immunoglobulin light chain amyloidosis and 12 transthyretin related) underwent Gd-CMR.

RESULTS

Gd enhancement was detected in 16 of 21 (76%) patients. Sixty six of 357 (18%) segments were enhanced, more often at the mid ventricular level. Transmural extension of enhancement within each patient significantly correlated with left ventricular (LV) end systolic volume (r = 0.58). The number of enhanced segments correlated with LV end diastolic volume (r = 0.76), end systolic volume (r = 0.6), and left atrial size (r = 0.56). Segments with > 50% extensive transmural enhancement more often were severely hypokinetic or akinetic (p = 0.001). Patients with > 2 enhanced segments had significantly lower 12 lead QRS voltage and Sokolow-Lyon index. No relation was apparent with any other clinical, morphological, functional, or histological characteristics.

CONCLUSION

Gd enhancement is common but not universally present in CA, probably due to expansion of infiltrated interstitium. The segmental and transmural distribution of the enhancement is highly variable, and mid-ventricular regions are more often involved. Enhancement appears to be associated with impaired segmental and global contractility and a larger atrium.

Multidetector CT: a new gold standard in the diagnosis of pulmonary embolism? State of the art and diagnostic algorithms

PURPOSE

From the early 90s, spiral CT technology has considerably changed the diagnostic capability of Pulmonary Embolism (PE), giving a direct vision of intravascular thrombi. Further technological progress has strengthened its diagnostic impact leading to an essential role in clinical practice. The advent of Multi-Detector CT (MDCT) has subsequently increased the reliability of this technique to the point of undermining the role of pulmonary angiography as the gold standard and occupying a central position in diagnostic algorithms. The aim of this paper is to appraise this evolution by means of a meta-analysis of the relevant literature from 1995 to 2004.

RESULTS

The review of the literature showed the sensitivity and specificity of CT to have increased from 37-94% and 81-100% (single-detector CT) to 87-94% and 94-100% (4-channel multidetector CT), especially thanks to the possibility of depicting subsegmental clots, with an interobserver agreement of 0.63-0.94 (k).

CONCLUSIONS

CT is one of the most reliable and effective methods in the diagnosis is PE, with the advantage of being extremely fast and providing alternative diagnoses. Recent improvements in MDCT technology confers the highest value of diagnostic accuracy with respect to other imaging modalities such as scintigraphy, angiography, MRI, D-dimer assay and Doppler US.

Magnetic resonance imaging evaluation of aortic elastic properties as early expression of Marfan syndrome

In Marfan syndrome, early identification and treatment of aortic involvement could improve prognosis, but clinical diagnosis may be difficult at a young age, before aortic dilation occurs. The aim of this study was to evaluate biomechanical aortic properties in Marfan patients and in their relatives to identify an early index of aortic involvement. A magnetic resonance imaging (MRI) morphologic and functional study of the thoracic aorta was performed in 20 Marfan patients, 15 family members, and 14 healthy volunteers as a control group. The aorta was imaged in the oblique sagittal plane by spin-echo sequence. A high-resolution gradient-echo sequence was then applied in the axial plane at the level of ascending supravalvular aorta to evaluate aortic distensibility. Aortic distensibility (mm Hg(-1) was significantly different in the three groups (ANOVA, p = 0.0001). Aortic distensibility was sensibly reduced in Marfan patients (0.0085 +/- 0.006 vs. 0.025 +/- 0.006 control group, p < 0.05). No significant correlation was found between aortic area and distensibility. Aortic distensibility was reduced also in family members (0.016 +/- 0.011 vs. 0.025 +/- 0.006 control group, p < 0.05). Among them, 4 subjects showed aortic diameters to the upper limit of the normal range, whereas the other 11 presented normal aortic diameters. Intraobserver and interobserver reproducibility for diastolic measurement was 1.2% and 0.4%, respectively, and 1.1% and 0.3%, respectively, for systolic measurement. MRI is an accurate technique in detecting abnormal aortic elastic properties in Marfan patients. Abnormal ascending aorta distensibility may constitute an index of early aortic involvement before dilation occurs.

A mutation in the latency-related gene of bovine herpesvirus 1 leads to impaired ocular shedding in acutely infected calves

Bovine herpesvirus 1 (BHV-1) is an important pathogen of cattle, and infection is usually initiated in the ocular or nasal cavity. Like other alphaherpesviruses, BHV-1 establishes latency in sensory neurons but has the potential of reactivating from latency and spreading. The only abundant viral transcript expressed during latency is the latency-related (LR) RNA, which is alternatively spliced in trigeminal ganglia during acute infection (L. R. Devireddy and C. Jones, J. Virol. 72:7294-7301, 1998). LR gene products inhibit cell cycle progression (Y. Jiang, A. Hossain, M. T. Winkler, T. Holt, A. Doster, and C. Jones, J. Virol. 72:8133-8142, 1998) and chemically induced apoptosis (J. Ciacci-Zannela, M. Stone, G. Henderson, and C. Jones. J. Virol. 73:9734-9740, 1999). Although these studies suggest that LR gene products play an important role in the latency/pathogenesis of BHV-1, construction of a mutant is necessary to test this hypothesis. Because the bICP0 gene overlaps and is antisense to the LR gene, it was necessary to mutate the LR gene without altering bICP0 expression. This was accomplished by inserting three stop codons near the beginning of the LR RNA, thus interfering with expression of proteins expressed by the LR RNA. The LR mutant virus grew with wild-type (WT) efficiency in bovine kidney (MDBK) cells and expressed bICP0 at least as efficiently as WT BHV-1 or the LR rescued virus. When calves were infected with the LR mutant, we observed a dramatic decrease (3 to 4 log units) in ocular shedding during acute infection relative to WT or the LR rescued virus. In contrast, shedding of the LR mutant from the nasal cavity was not significantly different from that of the WT or the LR rescued virus. Calves infected with the LR mutant exhibited mild clinical symptoms, but they seroconverted. Neutralizing antibody titers were lower in calves infected with the LR mutant, confirming reduced growth. In summary, this study suggests that an LR protein promotes ocular shedding during acute infection of calves.

Cisplatin, etoposide, and paclitaxel with granulocyte colony-stimulating factor in untreated patients with extensive-stage small cell lung cancer: a phase II trial of the Southwest Oncology Group

PURPOSE

This study was designed to determine the efficacy and toxicity of cisplatin, etoposide, and paclitaxel (PET) in patients with extensive-stage small cell lung cancer (ES-SCLC).

EXPERIMENTAL DESIGN

Chemo-naive adult patients with a performance status (PS) of 0-2 and adequate organ function were eligible. Patients received cisplatin 80 mg/m(2) i.v., etoposide 80 mg/m-2 i.v., and paclitaxel 175 mg/m(2) i.v. over a 3-h period on day 1 followed by etoposide 160 mg/m(2) p.o. on days 2 and 3 every 21 days for six cycles. G-CSF 5 microg/kg was injected s.c. on days 4-14.

RESULTS

Eighty-eight patients were assessable. The median age was 60 years; 50% were male, 78% had PS of 0-1, 28% had PS of 2, 53% had multiple sites, and 13% had brain involvement. The overall response rate was 57% with 10 (12%) of 84 patients achieving a complete response. Median progression-free survival was 6 months [95% confidence interval (CI), 5-7 months] with a median survival of 11 months (95% CI, 8-13 months) and a 1-year survival rate of 43% (95% CI, 33-54%). Six patients (7%) died from toxicity. Grade 5 toxicity occurred in 3 (14%) of 22 patients (with a PS of 2) versus 3 (5%) of 61 patients (with a PS of 0-1; P, not significant). Grade 4 neutropenia developed in 40% of patients. Grade 3 nonhematological toxicities were primarily nausea (20%), vomiting (16%), and fatigue (14%).

CONCLUSION

The survival result achieved was superior to prior SWOG experiences; however, the toxic death rate was unacceptably high in PS-2 patients. These results provide the largest database for the ongoing randomized Intergroup trial comparing PET to cisplatin+etoposide in PS-0-1 patients with ES-SCLC.

[Non-surgical treatment of aortic aneurysms and dissections: indications, strategies and outcome]

PURPOSE

The endovascular treatment of the thoracic aorta is an effective alternative to open surgical repair and offers a therapeutic option even to patients at high risk for surgery. Our experience in the treatment of different diseases of descending thoracic aorta is reported.

MATERIAL AND METHODS

Between July 1997 and January 2001, 50 patients were selected for endovascular treatment: 36/50 patients presented high risk for conventional surgery. Six patients presented clinical and imaging features suggesting impending rupture and were treated on emergency basis. The stent-graft prosthesis was individually manufactured or selected on the basis of spiral CT or MRI measurements.

RESULTS

Endovascular stent positioning and deployment was technically successful in 49 cases. In one patient the tortuosity of the aortic arch prevented graft deployment. Complete aneurysm exclusion was achieved in 48 cases as assessed by post-procedure angiography and TEE. One proximal endoleak was noted and surgical conversion was performed 40 days later. There were no intraoperative mortality or complications. One patient presented extension of dissection at the 8th postoperative day and required of surgical repair. CT scan showed an endoleak in 4 cases that sealed spontaneously in three cases while the fourth case was treated by graft extension. In the long term two secondary endoleak were observed (12 and 24 months after the procedure).

CONCLUSIONS

Endovascular stent-graft repair provides a less invasive opportunity to patients affected by thoracic aortic disease. Careful cases selection is the first postulate for the efficacy and safety of the procedure.

Assessment through environmental and biological measurements of total daily exposure to volatile organic compounds of office workers in Milan, Italy

Personal exposure to total volatile organic compounds (TVOCs), benzene and toluene of 100 Milan office workers was assessed through personal air monitoring at home, in the office, and during commuting. Biological monitoring was performed by measuring blood benzene and toluene concentrations together with urinary trans-trans-muconic acid (t,t-MA) and cotinine at the end of the monitoring period. The geometric means of the total 24-h personal exposure were 514 micrograms/m3 for TVOCs, 21.2 micrograms/m3 for benzene and 35.2 micrograms/m3 for toluene. Daily exposure to the volatile organic compounds was almost totally determined by indoor exposure at home and in the office, with a minor contribution in the transport means. An important factor determining exposure to benzene was found to be tobacco smoke, both for active smokers and for non-smokers exposed to environmental tobacco smoke (ETS). All the mean levels of the biological indicators were significantly higher in active smokers than in non-smoking subjects non-exposed to ETS; urine cotinine and t,t-MA levels were also significantly higher in non-smokers exposed to ETS than in non-smokers non-exposed to ETS.

Army and Air Force leadership in the Prostate Cancer Prevention Trial

Prostate cancer is now the most common solid tumor in men in the United States. Although the current public health approach to this disease is early diagnosis and treatment, investigations are also focusing on the possibility of disease prevention. The Prostate Cancer Prevention Trial, begun in 1993, has completed recruitment of 18,000 men who will be randomized to receive either finasteride or placebo to determine if finasteride can prevent the development of this disease. Both Army and Air Force institutions are participating in this trial, with four Department of Defense institutions contributing over 10% of the patients randomized. The results of this study may have a major impact on active duty personnel for whom prevention of prostate cancer may become possible.