Cardiac Imaging Update

Transesophageal Echocardiography Screening in Subjects with a First Cerebrovascular Ischemic Event.

J Stroke Cerebrovasc Dis. 2010 Aug 31;

Authors: Young KC, Benesch CG

Our goal was to develop decision guides to predict the presence of a high-risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects age >/=18 years who underwent TEE after a first ischemic event and were admitted to our stroke service between 2004 and 2007 (n = 287). A high-risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints, using multivariate techniques and receiver operating characteristic curves. We found that 14.3% of the subjects had a high-risk source, and an additional 61.3% had a potential (or low-risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high-risk source of embolus. TEE would be recommended for nondiabetic individuals age >/=66 years (sensitivity, 68%; specificity, 76%). The area under the curve (AUC) for detecting a high-risk source was 0.773. TEE results changed medications or clinical management in 30.3% of the subjects. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event age >/=66 years may benefit from TEE. Although changes in management occurred in at least 30% of our cohort, no factors that predicted a change in management better than chance alone could be identified.

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Quadricuspid aortic valve by using intraoperative transesophageal echocardiography.

Cardiovasc Ultrasound. 2010 Sep 2;8(1):36

Authors: Xiao Z, Meng W, Zhang E

ABSTRACT: Quadricuspid aortic valve is a rare congenital malformation of the aortic valve. Its diagnosis is often missed even with the use of transthoracic echocardiogram. Many of these patients progress to aortic incompetence later in life, hence requiring surgical intervention. In the case described in this report, a 61-year-old woman is presented with the features of congestive heart failure. The preoperative transthoracic echocardiogram disclosed a moderate to severe aortic valve insufficiency but failed to reveal the quadricuspid aortic value anomaly. This case underscores the important role of three-dimensional transesophageal echocardiography for the diagnosis of quadricuspid aortic valve.

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Premature aortic stiffness in systemic lupus erythematosus by transesophageal echocardiography.

Lupus. 2010 Sep 2;

Authors: Roldan CA, Joson J, Qualls C, Sharrar J, Sibbitt W

To assess aortic stiffness by transesophageal echocardiography (TEE) and to determine its clinical predictors and relation to age, blood pressure, renal function, and atherosclerosis, 50 patients with systemic lupus erythematosus (SLE), 94% women, with a mean age of 38 +/- 12 years, and 22 age and gender-matched healthy controls underwent clinical and laboratory evaluations and multiplane TEE to assess stiffness, intima-media thickness (IMT), and plaques of the proximal, mid, and distal descending thoracic aorta. Stiffness at each level and overall aortic stiffness by the pressure-strain elastic modulus was higher in patients than in controls after adjusting for age (overall, 8.25 +/- 4.13 versus 6.1 +/- 2.5 Pascal units, p = 0.01). Patients had higher aortic stiffness than controls after adjusting both groups to the same mean age, blood pressure, creatinine, and aortic IMT (p = 0.005). Neither IMT nor plaques were predictors of aortic stiffness. Moreover, normotensive patients, those without aortic plaques, and non-smokers had higher stiffness than controls (all p < 0.05). Age at SLE diagnosis and non-neurologic damage score were the only SLE-specific independent predictors of aortic stiffness (both p

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Negative predictive value of normal adenosine-stress cardiac MRI in the assessment of coronary artery disease and correlation with semiquantitative perfusion analysis.

J Magn Reson Imaging. 2010 Sep;32(3):615-21

Authors: Pilz G, Eierle S, Heer T, Klos M, Ali E, Scheck R, Wild M, Bernhardt P, Hoefling B

PURPOSE:: To prospectively determine the negative predictive value of normal adenosine stress cardiac MR (CMR) in routine patients referred for evaluation of coronary artery disease (CAD), predominantly with intermediate to high pretest risk. MATERIALS AND METHODS:: Consecutive patients referred for coronary angiography were examined in a 1.5 Tesla whole-body scanner before catheterization. A total of 158 patients with normal CMR on qualitative assessment were included, and semiquantitative perfusion analysis was performed. Significant CAD was regarded as luminal narrowing of >/=70% in coronary angiography. RESULTS:: In the 158 study patients, negative predictive value of normal adenosine-stress CMR for significant CAD was 96.2% (for stenosis >/=90%: 98.1%). True-negative and false-negative patients were comparable regarding clinical presentation, risk factors, and CMR findings. Semiquantitative perfusion analysis gave significantly prolonged arrival time index and peak time index in the false-negative group. Using cutoff values >1.8 for arrival time index or >1.2 for peak time index, the CMR negative predictive value increased to 98.7% (for stenosis >/=90%: to 100%). CONCLUSION:: The very high negative predictive value for CAD supports CMR-based decision making for the indication to coronary angiography. Semiquantitative perfusion analysis seems promising to identify the small group of CAD patients not detectable by qualitative CMR assessment. J. Magn. Reson. Imaging 2010;32:615-621. (c) 2010 Wiley-Liss, Inc.

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Incidental detection of skeletal metastases from thyroid cancer during myocardial perfusion imaging.

Hell J Nucl Med. 2010 May-Aug;13(2):169-70

Authors: Kashyap R, Balasubramanian Harisankar CN, Parmar M, Bhattacharya A, Singh B, Mittal BR

To the Editor: The HJNM has published cases of various incidental findings on myocardium perfusion imaging (MPI). We report another incidental finding on MPI that may be important for the treatment schedule of the patients studied. A 65 years old female patient with follicular thyroid cancer was subjected to stress MPI using technetium-99m tetrofosmin ((99m)Tc-TF) in order to exclude coronary artery disease, as part of tests performed before anaesthesia and total thyroidectomy. She was hypertensive and diabetic and complained of symptoms equivalent to angina. Cardiac stress was given with dobutamine, starting with a dose of 10mcg/kg to a maximum of 40mcg/kg. (99m)Tc-TF was injected 1min before discontinuing the infusion of dobutamine. A second injection comprising 777MBq of the radiotracer was administered after 3hrs at rest. Abnormal tracer accumulation was noted adjoining the myocardium, in both stress and rest images. A lateral image acquired in prone position with the breast hanging did not show any abnormal uptake in the breast tissue. Another focus of abnormally increased tracer uptake, at the site of a palpable swelling, was noticed in the occipital region. Subsequent whole body imaging was performed using the already injected dose, of (99m)Tc-TF for rest MPI that showed one more focus of faint tracer uptake at the left pelvic region. Single photon emission tomography /computerized tomography (SPET/CT) examination of the thoracic region with (99m)Tc-TF injected for rest MPI localized the abnormal focus to be in the 4th left rib near the costochondral junction. No hybrid imaging was performed for the pelvic focus after the MPI. The patient was subjected to total thyroidectomy and metastasectomy of metastasis at the skull. A whole body iodine-131 ((131)I) scan performed 48h after oral administration of 55.5MBq of (131)I showed residual tracer uptake at the occipital region, a focal tracer uptake in the chest and another focus in the pelvis. Hybrid imaging localized the tracer uptake in the pelvis, at the acetabular margin. Several case reports of incidental extracardiac uptake of the radiotracer have been reported in the literature. Metastases from thyroid cancer to the skull are seen in approximately 2.5%-5.8% of these cases, while skeletal metastases are seen in approximately 10%-40%. The patient was further treated with (131)I as all metastases were iodine avid. Due to the diagnosis of multiple skeletal metastases the (131)I dose was increased to 150mCi. The patient is on regular follow up and is doing well.In conclusion, incidental findings in MPI performed by hybrid SPET/CT showed skeletal metastases of thyroid cancer and altered treatment procedure.

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