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Carbucicchio C, Guarracini F, Schiavone M, Gasperetti A, Conte E, Preda A, Cellucci S, De Iuliis P, Catto V, Mushtaq S, Mancini ME, Marchetti F, Bianchini L, Tundo F, Moltrasio M, Andreini D, Pontone G, Tondo C. Preprocedural imaging with cardiac computed tomography for endo-epicardial ventricular tachycardia ablation. Heart Rhythm 2024:S1547-5271(24)02738-3. [PMID: 38908459 DOI: 10.1016/j.hrthm.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Studies evaluating the systematic use of cardiac computed tomography (CCT) for the preprocedural assessment of myocardial fibrosis are limited. Their implementation in the electrophysiology workflow has not been extensively described. OBJECTIVE This study aimed to explore the degree of concordance between CCT and electroanatomic mapping (EAM) for the evaluation of cardiac fibrosis in patients undergoing endo-epicardial ventricular tachycardia (VT) ablation. METHODS From November 2017 to December 2021, patients undergoing endo-epicardial VT catheter ablation with CCT as the only source of preprocedural scar assessment were prospectively enrolled. After image integration, myocardial fibrosis detected with CCT was compared with low-voltage areas identified by endo-epicardial EAM. Postprocedural VT recurrences of this approach were evaluated after at least 1 year of follow-up. RESULTS The study enrolled 35 patients (mean age, 60.7 ± 13.2 years; 94.2% male). The most common underlying arrhythmic substrate was dilated cardiomyopathy (48.6%). CCT was employed for contraindications to cardiac magnetic resonance, such as unstable VTs (31.4%) or nonconditional implantable cardioverter-defibrillators (28.6%), but also for patients' and operators' preferences (14.3%-25.7%). Myocardial fibrosis was correctly identified by CCT and EAM, with strong agreement between these techniques both overall (Cohen κ for agreement, 0.933) and in per-segment analysis (κ ranging from 0.796 to 1.0). Ischemic patients showed the best correlation (κ = 1.000), whereas myocarditis showed the worst (κ = 0.750). After a median follow-up of 14 (12-24) months, 1-year freedom from recurrences was achieved in 74.3% patients; overall freedom from recurrences was 60.0%. CONCLUSION A CCT-based preprocedural assessment before VT ablation is feasible, showing high diagnostic concordance with EAM in detecting myocardial fibrosis.
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Affiliation(s)
- Corrado Carbucicchio
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
| | | | - Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Edoardo Conte
- Clinical Cardiology, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy
| | - Alberto Preda
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Selene Cellucci
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Valentina Catto
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Saima Mushtaq
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Maria Elisabetta Mancini
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Francesca Marchetti
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Lorenzo Bianchini
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Fabrizio Tundo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Massimo Moltrasio
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Daniele Andreini
- Clinical Cardiology, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Emoto T, Kidoh M, Oda S, Sakabe D, Morita K, Hatemura M, Nakaura T, Nagayama Y, Inoue T, Funama Y, Takashio S, Tsujita K, Hirai T. Diagnostic performance of unenhanced electrocardiogram-gated cardiac CT for detecting myocardial edema. Medicine (Baltimore) 2024; 103:e38295. [PMID: 38758838 PMCID: PMC11098205 DOI: 10.1097/md.0000000000038295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
To assess the diagnostic performance of unenhanced electrocardiogram (ECG)-gated cardiac computed tomography (CT) for detecting myocardial edema, using MRI T2 mapping as the reference standard. This retrospective study protocol was approved by our institutional review board, which waived the requirement for written informed consent. Between December 2017 to February 2019, consecutive patients who had undergone T2 mapping for myocardial tissue characterization were identified. We excluded patients who did not undergo unenhanced ECG-gated cardiac CT within 3 months from MRI T2 mapping or who had poor CT image quality. All patients underwent unenhanced ECG-gated cardiac CT with an axial scan using a third-generation, 320 × 0.5 mm detector-row CT unit. Two radiologists together drew regions of interest (ROIs) in the interventricular septum on the unenhanced ECG-gated cardiac CT images. Using T2 mapping as the reference standard, the diagnostic performance of unenhanced cardiac CT for detecting myocardial edema was evaluated by using the area under the receiver operating characteristic curve with sensitivity and specificity. Youden index was used to find an optimal sensitivity-specificity cutoff point. A cardiovascular radiologist independently performed the measurements, and interobserver reliability was assessed using intraclass correlation coefficients for CT value measurements. A P value of <.05 was considered statistically significant. We included 257 patients who had undergone MRI T2 mapping. Of the 257 patients, 35 patients underwent unenhanced ECG-gated cardiac CT. One patient was excluded from the study because of poor CT image quality. Finally, 34 patients (23 men; age 64.7 ± 14.6 years) comprised our study group. Using T2 mapping, we identified myocardial edema in 19 patients. Mean CT and T2 values for 34 patients were 46.3 ± 2.7 Hounsfield unit and 49.0 ± 4.9 ms, respectively. Mean CT values moderately correlated with mean T2 values (Rho = -0.41; P < .05). Mean CT values provided a sensitivity of 63.2% and a specificity of 93.3% for detecting myocardial edema, with a cutoff value of ≤45.0 Hounsfield unit (area under the receiver operating characteristic curve = 0.77; P < .01). Inter-observer reproducibility in measuring mean CT values was excellent (intraclass correlation coefficient = 0.93; [95% confidence interval: 0.86, 0.96]). Myocardial edema could be detected by CT value of myocardium in unenhanced ECG-gated cardiac CT.
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Affiliation(s)
- Takafumi Emoto
- Department of Central Radiology, Kumamoto University Hospital, Chuo-ku, Kumamoto, Japan
| | - Masafumi Kidoh
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Daisuke Sakabe
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Kosuke Morita
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Masahiro Hatemura
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Takeshi Nakaura
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Yasunori Nagayama
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Taihei Inoue
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
| | - Yoshinori Funama
- Department of Medical Physics, Faculty of Life Sciences, Chuo-ku, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Toshinori Hirai
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Chuo-ku, Kumamoto, Japan
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Bai XH, Yin J, Yu SY, Shu YP, Lu ZP, Jiang KR, Xu Q. Extracellular volume fraction derived from dual-energy CT: a potential predictor for acute pancreatitis after pancreatoduodenectomy. Eur Radiol 2024:10.1007/s00330-024-10750-3. [PMID: 38760508 DOI: 10.1007/s00330-024-10750-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/07/2024] [Accepted: 03/09/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES To investigate the value of extracellular volume (ECV) fraction and fat fraction (FF) derived from dual- energy CT (DECT) for predicting postpancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD). METHODS This retrospective study included patients who underwent DECT and PD between April 2022 and September 2022. PPAP was determined according to the International Study Group for Pancreatic Surgery (ISGPS) definition. Iodine concentration (IC) and FF of the pancreatic parenchyma were measured on preoperative DECT. The ECV fraction was calculated from iodine map images of the equilibrium phase. The independent predictors for PPAP were assessed by univariate and multivariable logistic regression analysis and receiver operating characteristic (ROC) curve analysis. RESULTS Sixty-nine patients were retrospectively enrolled (median age, 60 years; interquartile range, 55-70 years; 47 men). Of these, nine patients (13.0%) developed PPAP. These patients had lower portal venous phase IC, equilibrium phase IC, FF, and ECV fraction, and higher pancreatic parenchymal-to-portal venous phase IC ratio and pancreatic parenchymal-to-equilibrium phase IC ratio, compared with patients without PPAP. After multivariable analysis, ECV fraction was independently associated with PPAP (odd ratio [OR], 0.87; 95% confidence interval [CI]: 0.79, 0.96; p < 0.001), with an area under the curve (AUC) of 0.839 (sensitivity 100.0%, specificity 58.3%). CONCLUSIONS A lower ECV fraction is independently associated with the occurrence of PPAP after PD. ECV fraction may serve as a potential predictor for PPAP after PD. CLINICAL RELEVANCE STATEMENT DECT-derived ECV fraction of pancreatic parenchyma is a promising biomarker for surgeons to preoperatively identify patients with higher risk for postpancreatectomy acute pancreatitis after PD and offer selective perioperative management. KEY POINTS PPAP is a complication of pancreatic surgery, early identification of higher-risk patients allows for risk mitigation. Lower DECT-derived ECV fraction was independently associated with the occurrence of PPAP after PD. DECT aids in preoperative PAPP risk stratification, allowing for appropriate treatment to minimize complications.
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Affiliation(s)
- Xiao-Han Bai
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Jie Yin
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Si-Yao Yu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yu-Ping Shu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Zi-Peng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Kui-Rong Jiang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
| | - Qing Xu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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Jiang Y, Ye J, Yang Y, Zhang Y, Yan X, Qiang W, Chen H, Xu S, Zhou L, Qi R, Zhang Q. Prognostic value of measurement of myocardial extracellular volume using dual-energy CT in heart failure with preserved ejection fraction. Sci Rep 2024; 14:7504. [PMID: 38553622 PMCID: PMC10980678 DOI: 10.1038/s41598-024-58271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/27/2024] [Indexed: 04/02/2024] Open
Abstract
Diffuse myocardial fibrosis is associated with adverse outcomes in heart failure with preserved ejection fraction (HFpEF). Dual-energy CT (DECT) can noninvasively assess myocardial fibrosis by quantification of extracellular volume (ECV) fraction. This study evaluated the association between ECV measured by DECT and clinical outcomes in patients with HFpEF. 125 hospitalized HFpEF patients were enrolled in this retrospective cohort study. ECV was measured using DECT with late iodine enhancement. The composite endpoint was defined as HFpEF hospitalization and all-cause mortality during the follow-up. During the median follow-up of 10.4 months, 34 patients (27.20%) experienced the composite outcomes, including 5 deaths; and 29 HFpEF hospitalizations. The higher DECT-ECV group had higher rates of composite outcomes than the low ECV group (log-rank X2 = 6.818, P = 0.033). In multivariate Cox regression analysis, the ECV (HR 1.17, 95% CI 1.06-1.30, P = 0.001) and NT-pro BNP (HR 2.83, 95% CI 1.16-6.88, P = 0.022) were independent risk factors for the adverse outcomes. Myocardial ECV measured using DECT was an independent risk factor for adverse outcomes in patients with HFpEF.
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Affiliation(s)
- Ying Jiang
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Jiaqi Ye
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Yang Yang
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Ying Zhang
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Xiaoyun Yan
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Wenhui Qiang
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Haixiao Chen
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Shuang Xu
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China
| | - Lei Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Rongxing Qi
- Department of Radiology, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China.
| | - Qing Zhang
- Department of General Practice, The Second Affiliated Hospital of Nantong University, Shengli Road No.666, Nantong, 226001, China.
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Cundari G, Marchitelli L, Pambianchi G, Catapano F, Conia L, Stancanelli G, Catalano C, Galea N. Imaging biomarkers in cardiac CT: moving beyond simple coronary anatomical assessment. LA RADIOLOGIA MEDICA 2024; 129:380-400. [PMID: 38319493 PMCID: PMC10942914 DOI: 10.1007/s11547-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
Cardiac computed tomography angiography (CCTA) is considered the standard non-invasive tool to rule-out obstructive coronary artery disease (CAD). Moreover, several imaging biomarkers have been developed on cardiac-CT imaging to assess global CAD severity and atherosclerotic burden, including coronary calcium scoring, the segment involvement score, segment stenosis score and the Leaman-score. Myocardial perfusion imaging enables the diagnosis of myocardial ischemia and microvascular damage, and the CT-based fractional flow reserve quantification allows to evaluate non-invasively hemodynamic impact of the coronary stenosis. The texture and density of the epicardial and perivascular adipose tissue, the hypodense plaque burden, the radiomic phenotyping of coronary plaques or the fat radiomic profile are novel CT imaging features emerging as biomarkers of inflammation and plaque instability, which may implement the risk stratification strategies. The ability to perform myocardial tissue characterization by extracellular volume fraction and radiomic features appears promising in predicting arrhythmogenic risk and cardiovascular events. New imaging biomarkers are expanding the potential of cardiac CT for phenotyping the individual profile of CAD involvement and opening new frontiers for the practice of more personalized medicine.
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Affiliation(s)
- Giulia Cundari
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giacomo Pambianchi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Federica Catapano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20090, Milano, Italy
- Humanitas Research Hospital IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089, Milano, Italy
| | - Luca Conia
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giuseppe Stancanelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Timóteo AT, Rosa SA, Brás PG, Ferreira MJV, Bettencourt N. Multimodality imaging in cardiac amyloidosis: State-of-the-art review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1084-1096. [PMID: 36218201 DOI: 10.1002/jcu.23271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 06/16/2023]
Abstract
Amyloidosis is a systemic disease, characterized by deposition of amyloid fibrils in various organs, including the heart. For the diagnosis of cardiac amyloidosis (CA) it is required a high level of clinical suspicion and in the presence of clinical, laboratorial, and electrocardiographic red flags, a comprehensive multimodality imaging evaluation is warranted, including echocardiography, magnetic resonance, scintigraphy, and computed tomography, that will confirm diagnosis and define the CA subtype, which is of the utmost importance to plan a treatment strategy. We will review the use of multimodality imaging in the evaluation of CA, including the latest applications, and a practical flow-chart will sum-up this evidence.
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Affiliation(s)
- Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Silvia Aguiar Rosa
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Heart Center, Hospital Cruz Vermelha Portuguesa, Lisbon, Portugal
| | - Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Maria João Vidigal Ferreira
- Faculty of Medicine, Coimbra Institute for Biomedical Imaging and Translational Research, Coimbra University, Coimbra, Portugal
- Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Fernández-Pérez GC, Fraga Piñeiro C, Oñate Miranda M, Díez Blanco M, Mato Chaín J, Collazos Martínez MA. Dual-energy CT: Technical considerations and clinical applications. RADIOLOGIA 2022; 64:445-455. [PMID: 36243444 DOI: 10.1016/j.rxeng.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/20/2022] [Indexed: 06/16/2023]
Abstract
Although dual-energy CT was initially described by Hounsfield in 1973, it remains underused in clinical practice. It is therefore important to emphasize the clinical benefits and limitations of this technique. Iodine mapping makes it possible to quantify the uptake of iodine, which is very important in characterizing tumors, lung perfusion, pulmonary nodules, and the tumor response to new treatments. Dual-energy CT also makes it possible to obtain virtual single-energy images and virtual images without iodinated contrast or without calcium, as well as to separate materials such as uric acid or fat and to elaborate hepatic iron overload maps. In this article, we review some of the clinical benefits and technical limitations to improve understanding of dual-energy CT and expand its use in clinical practice.
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Affiliation(s)
- G C Fernández-Pérez
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Grupo Recoletas, Valladolid, Spain.
| | - C Fraga Piñeiro
- Técnico Aplicaciones Siemens Healthineers, General Electric Company, Spain
| | - M Oñate Miranda
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain
| | - M Díez Blanco
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain
| | - J Mato Chaín
- Servicio de Radiodiagnóstico, Hospital Universitario Río Hortega, Valladolid, Spain
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Fernández-Pérez G, Fraga Piñeiro C, Oñate Miranda M, Díez Blanco M, Mato Chaín J, Collazos Martínez M. Energía Dual en TC. Consideraciones técnicas y aplicaciones clínicas. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhou Y, Geng D, Su GY, Chen XB, Si Y, Shen MP, Xu XQ, Wu FY. Extracellular Volume Fraction Derived From Dual-Layer Spectral Detector Computed Tomography for Diagnosing Cervical Lymph Nodes Metastasis in Patients With Papillary Thyroid Cancer: A Preliminary Study. Front Oncol 2022; 12:851244. [PMID: 35756662 PMCID: PMC9213667 DOI: 10.3389/fonc.2022.851244] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The current study evaluates the performance of dual-energy computed tomography (DECT) derived extracellular volume (ECV) fraction based on dual-layer spectral detector CT for diagnosing cervical lymph nodes (LNs) metastasis from papillary thyroid cancer (PTC) and compares it with the value of ECV derived from conventional single-energy CT (SECT). Methods One hundred and fifty-seven cervical LNs (81 non-metastatic and 76 metastatic) were recruited. Among them, 59 cervical LNs (27 non-metastatic and 32 metastatic) were affected by cervical root artifact on the contrast-enhanced CT images in the arterial phase. Both the SECT-derived ECV fraction (ECVS) and the DECT-derived ECV fraction (ECVD) were calculated. A Pearson correlation coefficient and a Bland–Altman analysis were performed to evaluate the correlations between ECVD and ECVS. Receiver operator characteristic curves analysis and the Delong method were performed to assess and compare the diagnostic performance. Results ECVD correlated significantly with ECVS (r = 0.925; p <0.001) with a small bias (−0.6). Metastatic LNs showed significantly higher ECVD (42.41% vs 22.53%, p <0.001) and ECVS (39.18% vs 25.45%, p <0.001) than non-metastatic LNs. By setting an ECVD of 36.45% as the cut-off value, optimal diagnostic performance could be achieved (AUC = 0.813), which was comparable with that of ECVS (cut-off value = 34.99%; AUC = 0.793) (p = 0.265). For LNs affected by cervical root artifact, ECVD also showed favorable efficiency (AUC = 0.756), which was also comparable with that of ECVS (AUC = 0.716) (p = 0.244). Conclusions ECVD showed a significant correlation with ECVS. Compared with ECVS, ECVD showed comparable performance in diagnosing metastatic cervical LNs in PTC patients, even though the LNs were affected by cervical root artifacts on arterial phase CT.
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Affiliation(s)
- Yan Zhou
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Di Geng
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guo-Yi Su
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xing-Biao Chen
- Section of Clinical Research, Philips Healthcare Ltd, Shanghai, China
| | - Yan Si
- Department of Thyroid Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mei-Ping Shen
- Department of Thyroid Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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10
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Lee LE, Chandrasekar B, Yu P, Ma L. Quantification of myocardial fibrosis using noninvasive T2-mapping magnetic resonance imaging: Preclinical models of aging and pressure overload. NMR IN BIOMEDICINE 2022; 35:e4641. [PMID: 34729828 DOI: 10.1002/nbm.4641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 05/02/2023]
Abstract
Noninvasive imaging of cardiac fibrosis is important for early diagnosis and intervention in chronic heart diseases. Here, we investigated whether noninvasive, contrast agent-free MRI T2 -mapping can quantify myocardial fibrosis in preclinical models of aging and pressure overload. Myocardial fibrosis and remodeling were analyzed in two animal models: (i) aging (15-month-old male CF-1 mice vs. young 6- to 8-week-old mice), and (ii) pressure overload (PO; by transverse aortic constriction in 4- to 5-month-old male C57BL/6 mice vs. sham-operated for 14 days). In vivo T2 -mapping was performed by acquiring data during the isovolumic and early diastolic phases, with a modified respiratory and ECG-triggered multiecho TurboRARE sequence on a 7-T MRI. Cine MRI provided cardiac morphology and function. A quantitative segmentation method was developed to analyze the in vivo T2 -maps of hearts at midventricle, apex, and basal regions. The cardiac fibrosis area was analyzed ex vivo by picro sirius red (PSR) staining. Both aged and pressure-overloaded hearts developed significant myocardial contractile dysfunction, cardiac hypertrophy, and interstitial fibrosis. The aged mice had two phenotypes, fibrotic and mild-fibrotic. Notably, the aged fibrotic subgroup and the PO mice showed a marked decrease in T2 relaxation times (25.3 ± 0.6 in aged vs. 29.9 ± 0.7 ms in young mice, p = 0.002; and 24.3 ± 1.7 in PO vs. 28.7 ± 0.7 ms in shams, p = 0.05). However, no significant difference in T2 was detected between the aged mild-fibrotic subgroup and the young mice. Accordingly, an inverse correlation between myocardial fibrosis percentage (FP) and T2 relaxation time was derived (R2 = 0.98): T2 (ms) = 30.45 - 1.05 × FP. Thus, these results demonstrate a statistical agreement between T2 -map-quantified fibrosis and PSR staining in two different clinically relevant animal models. In conclusion, T2 -mapping MRI is a promising noninvasive contrast agent-free quantitative technique to characterize myocardial fibrosis.
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Affiliation(s)
- Li E Lee
- Research Division/Biomolecular Imaging Center, Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri, USA
- Department of Physics and Astronomy, University of Missouri, Columbia, Missouri, USA
| | - Bysani Chandrasekar
- Research Division/Biomolecular Imaging Center, Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri, USA
- Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Ping Yu
- Department of Physics and Astronomy, University of Missouri, Columbia, Missouri, USA
| | - Lixin Ma
- Research Division/Biomolecular Imaging Center, Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri, USA
- Department of Physics and Astronomy, University of Missouri, Columbia, Missouri, USA
- Department of Radiology, University of Missouri, Columbia, Missouri, USA
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11
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Lembo M, Manzi MV, Mancusi C, Morisco C, Rao MAE, Cuocolo A, Izzo R, Trimarco B. Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease. J Hypertens 2022; 40:4-14. [PMID: 34582136 PMCID: PMC10871661 DOI: 10.1097/hjh.0000000000002967] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/19/2023]
Abstract
Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.
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Affiliation(s)
- Maria Lembo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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12
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Conte E, Mushtaq S, Muscogiuri G, Formenti A, Annoni A, Mancini E, Ricci F, Melotti E, Gigante C, Lorenza Z, Guglielmo M, Baggiano A, Maragna R, Giacari CM, Carbucicchio C, Catto V, Pepi M, Andreini D, Pontone G. The Potential Role of Cardiac CT in the Evaluation of Patients With Known or Suspected Cardiomyopathy: From Traditional Indications to Novel Clinical Applications. Front Cardiovasc Med 2021; 8:709124. [PMID: 34595219 PMCID: PMC8476802 DOI: 10.3389/fcvm.2021.709124] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/05/2021] [Indexed: 12/28/2022] Open
Abstract
After 15 years from its advent in the clinical field, coronary computed tomography (CCTA) is now widely considered as the best first-step test in patients with low-to-moderate pre-test probability of coronary artery disease. Technological innovation was of pivotal importance for the extensive clinical and scientific interest in CCTA. Recently, the advent of last generation wide-coverage CT scans paved the way for new clinical applications of this technique beyond coronary arteries anatomy evaluation. More precisely, both biventricular volume and systolic function quantification and myocardial fibrosis identification appeared to be feasible with last generation CT. In the present review we would focus on potential applications of cardiac computed tomography (CCT), beyond CCTA, for a comprehensive assessment patients with newly diagnosed cardiomyopathy, from technical requirements to novel clinical applications.
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Affiliation(s)
- Edoardo Conte
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Saima Mushtaq
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Giuseppe Muscogiuri
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Alberto Formenti
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Andrea Annoni
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Elisabetta Mancini
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Francesca Ricci
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Eleonora Melotti
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlo Gigante
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Zanotto Lorenza
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Marco Guglielmo
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Andrea Baggiano
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Riccardo Maragna
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlo Maria Giacari
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Corrado Carbucicchio
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Valentina Catto
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Mauro Pepi
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Daniele Andreini
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Gianluca Pontone
- Centro Cardologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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13
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Deux JF, Nouri R, Tacher V, Zaroui A, Derbel H, Sifaoui I, Chevance V, Ridouani F, Galat A, Kharoubi M, Oghina S, Guendouz S, Audureau E, Teiger E, Kobeiter H, Damy T. Diagnostic Value of Extracellular Volume Quantification and Myocardial Perfusion Analysis at CT in Cardiac Amyloidosis. Radiology 2021; 300:326-335. [PMID: 34100681 DOI: 10.1148/radiol.2021204192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background CT can provide information regarding myocardial perfusion and expansion of the extracellular space, which is relevant to patients with cardiac amyloidosis (CA). Purpose To evaluate the role of CT in the diagnosis and prognosis of CA. Materials and Methods In this prospective study (Commission National de l'Informatique et des Libertés registration no. 1431858), participants with CA, participants with nonamyloid cardiac hypertrophy (NACH), and participants without hypertrophy were included between April 2017 and December 2018. The confirmed diagnosis of CA was determined according to established criteria (ie, proven with positive bone scintigraphy or endomyocardial biopsy). All participants were imaged with dynamic CT perfusion imaging at whole-heart cardiac CT. Extracellular volume measured at CT and myocardial perfusion parameters calculated on CT perfusion maps were compared among different participant groups. Differences between continuous data were tested using the unpaired t test, Mann-Whitney rank-sum test, or the Kruskal-Wallis test. Results A total of 84 participants with CA, 43 participants with NACH, and 33 participants without hypertrophy were included. Participants with CA exhibited a higher value of extracellular volume measured at CT (mean, 54.7% ± 9.7 [standard deviation]) than participants with NACH (mean, 34.6% ± 9.1; P < .001) and participants without hypertrophy (mean, 35.9% ± 9.9; P = .001). Mean myocardial blood volume and mean myocardial blood flow were lower in participants with CA (mean myocardial blood volume: 4.05 mL/100 g of myocardium ± 0.80; mean myocardial blood flow: 73.2 mL/100 g of myocardium per minute ± 25.7) compared to participants with NACH (mean myocardial blood volume: 5.38 mL/100 g of myocardium ± 1.20, P < .001; mean myocardial blood flow: 89.6 mL/100 g of myocardium per minute ± 31.3, P = .007) and participants without hypertrophy (mean myocardial blood volume: 5.68 mL/100 g of myocardium ± 1.05; mean myocardial blood flow: 106.3 mL/100 g of myocardium per minute ± 29.8; P < .001 for both). Extracellular volume measured at CT (hazard ratio >0.56 vs ≤0.56 = 4.2 [95% CI: 1.4, 11.8]), mean slope (hazard ratio ≤3.0 sec-1 vs >3.0 sec-1 = 0.2 [95% CI: 0.1, 0.8]), and time to peak (hazard ratio >20 seconds vs ≤20 seconds = 11.6 [95% CI: 1.3, 101.6]) were predictive of mortality in participants with CA. Conclusion Participants with cardiac amyloidosis exhibited an increase in extracellular volume at CT and abnormal CT perfusion parameters. Extracellular volume and several perfusion parameters were predictive of mortality. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Zimmerman in this issue.
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Affiliation(s)
- Jean-François Deux
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Refaat Nouri
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Vania Tacher
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Amira Zaroui
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Haytham Derbel
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Islem Sifaoui
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Virgile Chevance
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Fourat Ridouani
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Arnault Galat
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Mounira Kharoubi
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Silvia Oghina
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Soulef Guendouz
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Etienne Audureau
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Emmanuel Teiger
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Hicham Kobeiter
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
| | - Thibaud Damy
- From the Department of Radiology (J.F.D., R.N., V.T., H.D., I.S., V.C., F.R., H.K.), Department of Cardiology (A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), National Referral Centre for Cardiac Amyloidosis (J.F.D., A.Z., A.G., M.K., S.O., S.G., E.T., T.D.), and Department of Public Health (E.A.), Henri Mondor Hospital, University Paris Est Créteil, Assistance Publique-Hôpitaux de Paris, 51 av Mal de Lattre de Tassigny, 94000 Créteil, France
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14
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Mandoli GE, D'Ascenzi F, Vinco G, Benfari G, Ricci F, Focardi M, Cavigli L, Pastore MC, Sisti N, De Vivo O, Santoro C, Mondillo S, Cameli M. Novel Approaches in Cardiac Imaging for Non-invasive Assessment of Left Heart Myocardial Fibrosis. Front Cardiovasc Med 2021; 8:614235. [PMID: 33937354 PMCID: PMC8081830 DOI: 10.3389/fcvm.2021.614235] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/22/2021] [Indexed: 12/21/2022] Open
Abstract
In the past, the identification of myocardial fibrosis was only possible through invasive histologic assessment. Although endomyocardial biopsy remains the gold standard, recent advances in cardiac imaging techniques have enabled non-invasive tissue characterization of the myocardium, which has also provided valuable insights into specific disease processes. The diagnostic accuracy, incremental yield and prognostic value of speckle tracking echocardiography, late gadolinium enhancement and parametric mapping modules by cardiac magnetic resonance and cardiac computed tomography have been validated against tissue samples and tested in broad patient populations, overall providing relevant clinical information to the cardiologist. This review describes the patterns of left ventricular and left atrial fibrosis, and their characterization by advanced echocardiography, cardiac magnetic resonance and cardiac computed tomography, allowing for clinical applications in sudden cardiac death and management of atrial fibrillation.
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Affiliation(s)
- Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giulia Vinco
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, "G.d'Annunzio" University of Chieti-Pescara, Chieti, Italy.,Department of Clinical Sciences, Lund University, Malmö, Sweden.,Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Nicolò Sisti
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Oreste De Vivo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital Naples, Naples, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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15
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Hammer Y, Talmor-Barkan Y, Abelow A, Orvin K, Aviv Y, Bar N, Levi A, Landes U, Shafir G, Barsheshet A, Vaknin-Assa H, Sagie A, Kornowski R, Hamdan A. Myocardial extracellular volume quantification by computed tomography predicts outcomes in patients with severe aortic stenosis. PLoS One 2021; 16:e0248306. [PMID: 33690718 PMCID: PMC7946277 DOI: 10.1371/journal.pone.0248306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The extent of myocardial fibrosis in patients with severe aortic stenosis might have an important prognostic value. Non-invasive imaging to quantify myocardial fibrosis by measuring extracellular volume fraction might have an important clinical utility prior to aortic valve intervention. METHODS Seventy-five consecutive patients with severe aortic stenosis, and 19 normal subjects were prospectively recruited and underwent pre- and post-contrast computed tomography for estimating myocardial extracellular volume fraction. Serum level of galectin-3 was measured and 2-dimensional echocardiography was performed to characterize the extent of cardiac damage using a recently published aortic stenosis staging classification. RESULTS Extracellular volume fraction was higher in patients with aortic stenosis compared to normal subjects (40.0±11% vs. 21.6±5.6%; respectively, p<0.001). In patients with aortic stenosis, extracellular volume fraction correlated with markers of left ventricular decompensation including New York Heart Association functional class, left atrial volume, staging classification of aortic stenosis and lower left ventricular ejection fraction. Out of 75 patients in the AS group, 49 underwent TAVI, 6 surgical AVR, 2 balloon valvuloplasty, and 18 did not undergo any type of intervention. At 12-months after aortic valve intervention, extracellular volume fraction predicted the combined outcomes of stroke and hospitalization for heart failure with an area under the curve of 0.77 (95% confidence interval: 0.65-0.88). A trend for correlation between serum galectin-3 and extracellular volume was noted. CONCLUSION In patients with severe aortic stenosis undergoing computed tomography before aortic valve intervention, quantification of extracellular volume fraction correlated with functional status and markers of left ventricular decompensation, and predicted the 12-months composite adverse clinical outcomes. Implementation of this novel technique might aid in the risk stratification process before aortic valve interventions.
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Affiliation(s)
- Yoav Hammer
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Aryeh Abelow
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Katia Orvin
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Aviv
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Bar
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Landes
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Shafir
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hana Vaknin-Assa
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Sagie
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
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16
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Zhou Z, Gao Y, Wang H, Wang W, Zhang H, Wang S, Sun Z, Xu L. Myocardial extracellular volume fraction analysis in doxorubicin-induced beagle models: comparison of dual-energy CT with equilibrium contrast-enhanced single-energy CT. Cardiovasc Diagn Ther 2021; 11:102-110. [PMID: 33708482 DOI: 10.21037/cdt-20-798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Dual-energy CT (DECT) permits the simultaneous operation of two different kV levels, providing a potential method toward the assessment of diffuse myocardial fibrosis. The purpose of this study was to determine the accuracy of DECT for evaluation of the myocardial extracellular volume (ECV) fraction in comparison with single-energy CT (SECT). Methods Myocardial ECV was quantified in fifteen dogs using DECT and dynamic equilibrium SECT before and after doxorubicin administration. Cardiac magnetic resonance imaging (CMRI) was used to assess myocardial function. The histological collagen volume fraction (CVF) was calculated as the gold standard. The Bland-Altman analysis was performed to compare the agreement between DECT-ECV and SECT-ECV. The association among ECV values derived from DECT and SECT, CVF, and left ventricular ejection fraction (LVEF) were determined by correlation analysis. The variations of these values were evaluated using repeated ANOVA. Results The DECT- and SECT-ECV were increased with the elongation of modeling time (pre-modeling vs. 16-week models vs. 24-week models: DECT-ECV 24.1%±1.1%, 35.1%±1.3% and 37.6%±1.4%; SECT-ECV 22.9%±0.8%, 33.6%±1.2% and 36.3%±1.0%; n=30 in per-subject analysis, all P<0.05). Both ECV values of DECT and SECT correlated well with the histological CVF results (R=0.935 and 0.952 for the DECT-ECV and SECT-ECV; all P<0.001; n=13). Bland-Altman plots showed no significant differences between DECT- and SECT-ECV. Conclusions DECT-ECV correlated well with both SECT-ECV and histology, showing the feasibility of DECT in evaluating doxorubicin-induced diffuse myocardial interstitial fibrosis.
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Affiliation(s)
- Zhen Zhou
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yifeng Gao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongwei Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenjing Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongkai Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Zhonghua Sun
- Discipline of Medical Radiation Sciences, Curtin Medical School, Curtin University, Perth, Australia
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Han D, Tamarappoo B, Klein E, Tyler J, Chakravarty T, Otaki Y, Miller R, Eisenberg E, Park R, Singh S, Shiota T, Siegel R, Stegic J, Salseth T, Cheng W, Dey D, Thomson L, Berman D, Makkar R, Friedman J. Computed tomography angiography-derived extracellular volume fraction predicts early recovery of left ventricular systolic function after transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2021; 22:179-185. [PMID: 33324979 PMCID: PMC7822636 DOI: 10.1093/ehjci/jeaa310] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 10/30/2020] [Indexed: 01/04/2023] Open
Abstract
AIMS Recovery of left ventricular ejection fraction (LVEF) after aortic valve replacement has prognostic importance in patients with aortic stenosis (AS). The mechanism by which myocardial fibrosis impacts LVEF recovery in AS is not well characterized. We sought to evaluate the predictive value of extracellular volume fraction (ECV) quantified by cardiac CT angiography (CTA) for LVEF recovery in patients with AS after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS In 109 pre-TAVR patients with LVEF <50% at baseline echocardiography, CTA-derived ECV was calculated as the ratio of change in CT attenuation of the myocardium and the left ventricular (LV) blood pool before and after contrast administration. Early LVEF recovery was defined as an absolute increase of ≥10% in LVEF measured by post-TAVR follow-up echocardiography within 6 months of the procedure. Early LVEF recovery was observed in 39 (36%) patients. The absolute increase in LVEF was 17.6 ± 8.8% in the LVEF recovery group and 0.9 ± 5.9% in the no LVEF recovery group (P < 0.001). ECV was significantly lower in patients with LVEF recovery compared with those without LVEF recovery (29.4 ± 6.1% vs. 33.2 ± 7.7%, respectively, P = 0.009). In multivariable analysis, mean pressure gradient across the aortic valve [odds ratio (OR): 1.07, 95% confidence interval (CI): 1.03-1.11, P: 0.001], LV end-diastolic volume (OR: 0.99, 95% CI: 0.98-0.99, P: 0.035), and ECV (OR: 0.92, 95% CI: 0.86-0.99, P: 0.018) were independent predictors of early LVEF recovery. CONCLUSION Increased myocardial ECV on CTA is associated with impaired LVEF recovery post-TAVR in severe AS patients with impaired LV systolic function.
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Affiliation(s)
- Donghee Han
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Balaji Tamarappoo
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Eyal Klein
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Jeffrey Tyler
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Yuka Otaki
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Robert Miller
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Evann Eisenberg
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Rebekah Park
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Siddharth Singh
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Robert Siegel
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Jasminka Stegic
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Tracy Salseth
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Wen Cheng
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Damini Dey
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
- Biomedical Imaging Research Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Louise Thomson
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Daniel Berman
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - Raj Makkar
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
- Smidt Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
| | - John Friedman
- Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90028, USA
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18
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Muser D, Lavalle C, Guarracini F, Sassone B, Conte E, Magnani S, Notarstefano P, Barbato G, Sgarito G, Grandinetti G, Nucifora G, Ricci RP, Boriani G, De Ponti R, Casella M. Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia. J Cardiovasc Med (Hagerstown) 2020; 22:727-737. [PMID: 33136806 DOI: 10.2459/jcm.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.
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Affiliation(s)
- Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Pennsylvania, USA.,Cardiology Division, Santa Maria della Misericordia Hospital, Udine
| | - Carlo Lavalle
- Department of Cardiology, Policlinico Universitario Umberto I, Roma
| | | | - Biagio Sassone
- Cardiology Division, SS.ma Annunziata Hospital, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Edoardo Conte
- Cardiovascular Imaging Area and Clinical Cardiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Silvia Magnani
- Heart Rhythm Center, Langone Medical Center, New York University, New York, USA.,Ospedale San Paolo, Milan
| | | | | | - Giuseppe Sgarito
- Cardiology Division, ARNAS Ospedale Civico e Benfratelli, Palermo
| | | | - Gaetano Nucifora
- Cardiac Imaging Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo & Macchi Foundation, University of Insubria, Varese
| | - Michela Casella
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan.,Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona, Italy
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