T1 mapping of the right ventricle in heart transplant recipients: how does it correlate with endomyocardial biopsy findings?

Aim

Noninvasive detection of cardiac allograft rejection is highly desirable. We sought to assess how right ventricular (RV) T1 mapping correlates with endomyocardial biopsy findings.

Methods

All patients underwent right heart catheterization with biopsy and cardiac magnetic resonance (CMR) irrespective of symptoms, as part of the institutional registry protocol dedicated to heart transplant (HTx) recipients. CMR studies were performed using a 1.5 T scanner and analyses by using a commercially available software (CMR42, Circle CVI, Calgary, Canada). Endocardial and epicardial borders were drawn on end-systolic and end-diastolic phases for ventricular function analysis. For T1 measurements, region of interests located at the RV free-wall were drawn manually on midventricular short-axis slices avoiding blood pool and epicardial fat. Extracellular volume (ECV) was calculated as ECV = (1 − hematocrit) × (ΔR1 myocardium/ΔR blood), where R1 = 1/T1. Late gadolinium enhancement (LGE) images were also obtained using a phase-sensitive inversion recovery segmented gradient echo sequence. Hyperenhancement was assessed semi-quantitatively as segmental (2–3 cm) or diffuse (>3 cm). Allograft rejection was determined based on the severity of inflammatory infiltrates and myocyte damage on pathological specimens according to the standardized International Society for Heart and Lung Transplantation (ISHLT) nomenclature.

Results

In all, 61 paired studies were evaluated. None of the patients had heart failure symptoms. We defined 3 subgroups: Group I; never rejected (n=23), group II; biopsy remarkable for rejection (n=19) and group III; history of past rejection(s) (n=19). RV volumes and ejection fraction (EF) did not differ between the groups. However, rejections were nicely mirrored by T1 time and particularly by ECV. Of note, T1 time and ECV improved but not completely normalized after resolution of rejection. Overall, T1 time (cut off 1060ms) and ECV (cut off 35%) were sensitive (84%, both) and had high negative predictive values (88% and 87%, respectively) but not specific (43% and 52% respectively) for discriminating rejection related subclinical RV damage. Their specificity slightly improved to 52 and 61% respectively, if patients with previous rejection were excluded (Figure 1). LGE did not discriminate rejection.

Conclusion

RV volumes and EF are insensitive to detect allograft rejection. Native T1 time and ECV of the RV, as a means of extracellular expansion, likely reflect interstitial fibrosis, oedema, and inflammation that are typical for, but not limited to allograft rejection. Hence, these parameters can help to exclude rejection but have limited standalone value for making the nonivasive diagnosis due to their low specificity. These results cannot be extrapolated to the left ventricle.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): University of Baskent

AB0592 IS IT TIME TO DISSECTING GIANT CELL ARTERITIS INTO SUBPHENOTYPES? A CLOSE LOOK TO DATA OF EASTERN MEDITERRANEAN VASCULITIS CENTRE

Background

Patients with giant cell arteritis (GCA) have heterogeneity in terms of not only symptoms and findings but also extent of arterial involvement. In era of personalized medicine, therapy of patients is based on these diverse parameters.

Objectives

This study is aimed to identify subphenotypes of GCA, treatments have been used and outcomes in a prospective database of Eastern Mediterranean Vasculitis Centre.

Methods

Among 2454 patients recorded into Hacettepe University Vasculitis Research Centre database since October 2014; 181 of them were Takayasu’s arteritis and 89 of them GCA. 17 GCA patients were excluded due to missing data. Patients were grouped as Cranial GCA, Cranial GCA+ PMR, Cranial and LV GCA + PMR, Cranial and LV GCA, and LV GCA.

Demographic and clinical findings, histopathological and imaging data as well as outcome was collated for each subphenotype.

Results

Of 72 patients enrolled into further analysis, a female predominance (72.2%) was observed with mean age at diagnosis of 68.3(±8.2) years. Seventy-four percent of patients had cranial GCA (Figure 1) and leading subphenotype of all patients was only cranial GCA. Usage of temporal artery biopsy (TAB), temporal artery and axillary artery ultrasonography, and imaging modalities were different according to phenotypes of GCA.

Figure 1.

Distribution of GCA subphenotypes

Of the 38 patients having TAB, 20(42.9%) were consisted with GCA. The main histopathological finding were inflammation rich in lymphohistiocytic cells in the temporal artery (44.7%) and fragmentation and loss of integrity of the internal elastic lamina (36.8%).

All of the patients have been used corticosteroids with a median starting dose of 16 mg/day(8-64) had used pulse therapy. Any of conventional DMARDS (AZA, MTX, LEF, CYC) have been used in 60 of patients. In all cases, Tocilizumab was recommended after resistant/intolerant to conventional DMARDs (n=6).

Follow-up data was based on 64 patients. During a median 5,8 (±4.0) years follow-up, 6 (9.3%) patients deceased. Thirteen (20.3%) had one and more relapses, 8(61.5%) from isolated GCA group and 4(30.7%) from Only LV GCA group.

Conclusion

GCA is less frequent than TAK in our centre. Female predominance and a seventh decade of disease onset was observed in our cohort. Heterogeneity of disease was observed in or cohort along with different frequently used diagnostic confirmatory modality among subphenotypes. Relapse rate was 20 percent during a 6-year follow up with a 83% additional DMARD usage.

References

[1]K. Bates Gribbons1, Peter C Grayson1, et al Diagnostic Assessment Strategies and Disease Subsets in Giant Cell Arteritis: Data From an International Observational Cohort, Arthritis Rheumatology, 2020 Apr;72

Table 1.

Confirmatory modality of GCA diagnosis and treatments of subphenotypes

Only cranial GCA(n=38)Cranial GCA+PMR(n=6)Cranial GCA+LV GCA+ PMR(n=2)Cranial+LV GCA(n=5)LV GCA+PMR (n=7)Only LV GCA (n=14)Diagnosed confirmed by TAB(Total n=26)2042Temporal ultrasonography(Total n=24)182121PET CT/Vasculitis MR/VasculitisBT (Total n=22)13612Only steroidn=126213Pulse steroidn=148114Methotrexaten=351722167Leflunomiden=321Azatioprinen=19122113Cyclophosphamiden=11Tosilizumabn=862

Disclosure of Interests

None declared

Effects of mitral annular calcification on the outcomes of transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who carry intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequently seen in patients with aortic stenosis and it is associated with increased cardiovascular morbidity and mortality. It is reported that MAC is an independent predictor of all cause mortality after TAVI.

Aim

The aim of this study is to both evaluate the relationship between mitral annular calcification and TAVI related complications and mortality; and to define the predictors of both all cause mortality and permanent pacemaker implantation after TAVI.

Methods

All of the patients who underwent TAVI procedure due to severe aortic stenosis between 01.01.2020 and 01.06.2020 in our University Hospital were screened and patients fullfilling including criterias were enrolled. Patients' baseline demographic datas, laboratory, echocardiography and TAVI procedure related parameters were recorded. Outcomes are identified as follows; association between mitral annular calcification and TAVI related complications, establishment of the predictors of all cause mortality and permanent pacemaker implantation, definition of the in-hospital and all cause mortality rates.

Results

A total of 245 patients including 98 males (40%) and 147 females (60%) were enrolled in the study. The mean age of the population was 76,3±8,3 years. The mean left ventricular ejection fraction was % 54,8±11,4; aortic valve area was 0,74±0,14 cm2 and mean aortic transvalvular gradient was 47,0±14,3 mmHg. MAC was detected in 148 (% 60,4) patients (Table 1). In-hospital mortality was occurred in 14 (5,7%) cases. Permanent pacemaker implantation was performed in %17,8 (n=42) patients and all cause mortality was developed in 89 (36,3%) cases during the median 23,1 (11,6–44,3) months follow-up. Pericardial effusion (26,4% vs 12,4%; p=0,013) and contrast induced nephropathy (21,6% vs 7,2%; p=0,005) were developed more frequently in patients with MAC than without MAC (Table-2). Only the presence of MAC extending to left ventricular outflow tract was detected to be independent predictor of permanent pacemaker implantation requirement (HR: 3,32; p=0,002). All cause mortality predictors were established as; use of renin-angiotensin-aldosterone system blockers (HR: p=0,012), level of hemoglobin (HR: 0,79; p=0,006), severe mitral annular calcification (HR: 1,94; p=0,024) and atrial fibrillation development after TAVI (HR: 2,39; p=0,002). There was not any correlation between aortic valve area and MAC vloume (r=0,03; p=0,689), MAC Hounsfield Unit (r=−0,007; p=0,934) and MAC Agatston score (r=−0,08; p=0,290).

Discussion

MAC is associated with all cause mortality after TAVI and MAC extending to left ventricular outflow tract is an independent predictor of permanent pacemaker implantation requirement.

Funding Acknowledgement

Type of funding sources: None.

Giant pericardial cyst with a growing feature

Pericardial cysts are rare and benign lesions of the heart. They are usually asymptomatic and diagnosed incidentally on echocardiography or chest X-ray. In this report, we present an extremely rare case of a symptomatic giant pericardial cyst (11.6 cm × 10.6 cm × 8 cm) of a 55-year-old male patient who was admitted to our cardiology clinic. A thoracic computed tomography (CT) in 2013 revealed a giant pericardial cyst. However, at that time, the patient was asymptomatic and follow-up was recommended. Recent thoracic CT and magnetic resonance imaging demonstrated a significantly growing feature of this cyst with impending possible complications.

Does allograft size really matter in the long-term outcome of living donor kidney transplantation?

BACKGROUND

Increased allograft mass in living donor kidney transplantation has been recognized as a predictor factor of better short-term allograft function. We evaluated whether donor kidney volume adjusted for recipient body weight is associated with long-term allograft function in living donor kidney transplantation.

METHODS

We analyzed 67 living donors and their recipients who underwent transplantation between 2003 and 2007. Estimated glomerular filtration rate (eGFR) and serum creatinine levels at 1, 2, 3, 4, and 5 years post-transplantation were recorded for all recipients. Transplanted kidney volumes were measured using 3-D helical computed tomography scanning. A transplant kidney volume-recipient body weight (Vol/Wt) ratio was calculated for each donor-recipient pair. The subjects were divided into tertiles according to Vol/Wt ratios: low (<2.16), medium (2.16-2.88), and high (>2.88).

RESULTS

Vol/Wt ratio significantly correlated with recipient eGFR and serum creatinine levels at 1, 2, 3, and 4 years post-transplantation (r = .48, P < .0001; r = .46, P < .0001; r = .47, P < .0001; r = .26, P = .037, respectively, for eGFR; r = -.53, P < .0001; r = -.50, P < .0001; r = -.44, P < .0001; r = -.37, P = .003, respectively, for serum creatinine) but not at 5 years (r = .12, P = .406 for eGFR; r = -.21, P = .110 for serum creatinine). Whereas recipient eGFR increased significantly in a graded fashion among low to high Vol/Wt ratio groups during 1 to 3 years post-transplantation, there was no difference in eGFR values between Vol/Wt ratio groups at 4 and 5 years (P = .21 and .71, respectively).

CONCLUSION

Vol/Wt ratio is not associated with long-term allograft function in living donor kidney transplantation.

Coronary artery calcifications in hemodialysis patients and their correlation with the prevalence of erectile dysfunction

INTRODUCTION

Our aim in this study was to investigate the prevalence and correlation with coronary artery calcium scores (CACS) and erectile dysfunction (ED) among hemodialysis patients.

PATIENTS AND METHODS

Thirty-five male patients with chronic renal failure were selected to participate in this study. All patients underwent examinations for CACS using 16-channel multidetector computed tomography. The presence and severity of ED were determined by calculating the erectile function domain of the self-administered International Index of Erectile Function (IIEF).

RESULTS

The patients' ages ranged from 22 to 78 with a mean of 51.6 years. The mean duration of hemodialysis was 75.7 months (range = 12 to 232). Twenty-six patients had a history of one or more systemic diseases. The prevalence of any level of ED was 82.9% for all hemodialysis patients, and severe ED, 40%. The CACS was significantly higher among patients with severe ED (P = .032). The IIEF-5 score was also shown to have a moderate negative correlation with the CACS (r = -.420, P = .012). Age, duration of hemodialysis, body mass index, diabetes mellitus, hypertension, coronary heart diseases, hyperlipidemia, thyroid disease, depression, tobacco consumption, and medication were not associated with the presence of ED (P > .05).

CONCLUSION

ED is prevalent in hemodialysis patients. Although many possible factors contribute to ED, the severity of ED increases with greater CACS.

Bronchial to coronary artery fistulas: an important sign of silent coronary artery disease and potential complication during bronchial artery embolization

Coronary artery fistulas are rare and usually asymptomatic congenital anomalies generally diagnosed incidentally during coronary angiographies. Herein, we present a case of bronchial to coronary artery fistula which was diagnosed incidentally during bronchial artery embolization. Embolization was performed successfully without complication, and an underlying important coronary artery stenosis was subsequently found by coronary computed tomography angiography.

Myocardial delayed enhancement imaging: comparison of two-dimensional and three-dimensional inversion prepared fast gradient echo and steady state free precession sequences

We compared two-dimensional (2D) and three-dimensional (3D) inversion recovery prepared (IR) fast gradient echo (FGRE) and steady state free precession (SSFP) sequences used in myocardial delayed enhancement imaging. Twenty patients with a prior history of acute coronary syndrome were included in this study. Breath hold, ECG gated, segmented 2D and 3D IR_FGRE and SSFP sequences were acquired after intravenous administration of 0.15 mmol/kg gadodiamide-DTPA. Overall image quality, transmural extent of myocardial infarction, infarct volume, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and signal intensity ratio (SIR) were calculated and compared for each technique. 3D IR trueFISP showed significantly higher mean values of SNR and CNR compared with 3D IR turboFLASH, 2D IR turboFLASH and 2D IR trueFISP (p < 0.04 and p < 0.001). 3D IR_FGRE showed the second highest SNR and CNR. 3D IR_SSFP and 3D IR_FGRE allowed the imaging of the whole heart within a single breath-hold which reduced the imaging time significantly compared to 2D IR_FGRE and 2D IR_SSFP. 3D IR_SSFP and 3D IR_FGRE offer higher SNR, CNR and rapid acquisiton compared to 2D IR_SSFP and 2D IR_FGRE with adequate image quality.

Bleeding pulmonary artery pseudoaneurysm secondary to squamous cell lung cancer: computed tomography findings and endovascular management

A case of bleeding pulmonary artery pseudoaneurysm secondary to squamous cell lung cancer is reported. The patient presented with massive hemoptysis, diagnosis was made with multidetector computed tomography, and the pseudoaneurysm was successfully embolized with platinum coils. Hemoptysis ceased following the procedure.

Pseudoaneurysm of the brachial artery in two infants following accidental arterial puncture

A pseudoaneurysm is defined as an aneurysmatic sac surrounded byfibrous tissue instead of other vascular layers such as the muscular one. It is a rare incident in infants especially in the brachial artery. Blunt trauma and vascular access attempts are the most common etiologic factors. We present two infants with brachial artery pseudoaneurysm in the antecubital region following accidental arterial puncture.

Subaortic left brachiocephalic vein: computed tomography and magnetic resonance angiography findings

A case of anomalous (subaortic) position of the left brachiocephalic vein was incidentally detected on computed tomography images. Magnetic resonance angiography was performed to demonstrate the relationship of this vessel with other vascular structures. The anomalous vein was formed by the union of the left internal jugular and left subclavian veins. This vein passed downward along the left lateral side of the aortic arch, entered the aorticopulmonary window, descended in the mediastinum between the ascending aorta and the trachea and joined with the right brachiocephalic vein to form the superior vena cava. No cardiac anomalies accompanied the subaortic left brachiocephalic vein in the present case. We present the computed tomography and magnetic resonance angiography findings of this rare anomalous vein.

Bilateral supernumerary kidney: imaging findings

Supernumerary kidney is a rare urogenital anomaly with less than 100 cases reported. Bilateral supernumerary kidney is even more rare and to our knowledge there are three cases reported in the literature. Herein we present the computed tomography (CT), excretory urography (IVP), and CT angiography (CTA) findings in a patient with bilateral supernumerary kidneys.