Short-axis View Research Articles

Moderna Vaccine Induced Recurrent Myopericarditis

COVID-19 mRNA vaccine-related myocarditis and myopericarditis is a rare complication, with the US Centers for disease Control and Prevention reporting 4.2 per million females aged 12-29 years, dropping to 1.0 per million over 30, and exceptionally rare is recurrent myopericarditis requiring immunosuppressive therapy. We report a case of a 51-year-old female with no significant medical history presented to the emergency department with pleuritic chest pain, and progressive breathlessness 9 days after her first Moderna vaccine. Electrocardiography revealed widespread ST segment elevation with PR depression in the inferior leads. Her inflammatory markers were elevated with a C- reactive protein of 263. Transthoracic echocardiography revealed a moderate circumferential pericardial effusion with a maximum of 1.8cm adjacent to the lateral wall of the left ventricle in the parasternal short axis view and no evidence of tamponade physiology. The patient did not show initial response to anti-inflammatory therapy, and was commenced on steroid therapy, and subsequently immunosuppressive therapy, namely azathioprine, to manage disease activity. This case brings to light a rare but significant side effect of mRNA vaccine, and whilst this case should not impede vaccination efforts, it highlights that whilst the majority of patients get transient self-limiting myocardial inflammation, rare cases of prolonged myopericarditis may occur which may require prolonged immunosuppression.

Segmentation Enhanced Elastic Image Registration for 2D Speckle Tracking Echocardiography-Performance Study In Silico.

Although the two dimensional Speckle Tracking Echocardiography has gained a strong position among medical diagnostic techniques in cardiology, it still requires further developments to improve its repeatability and reliability. Few works have attempted to incorporate the left ventricle segmentation results in the process of displacements and strain estimation to improve its performance. We proposed the use of mask information as an additional penalty in the elastic image registration based displacements estimation. This approach was studied using a short axis view synthetic echocardiographic data, segmented using an active contour method. The obtained masks were distorted to a different degree, using different methods to assess the influence of the segmentation quality on the displacements and strain estimation process. The results of displacements and circumferential strain estimations show, that even though the method is dependent on the mask quality, the potential loss in accuracy due to the poor segmentation quality is much lower than the potential accuracy gain in cases where the segmentation performs well.

Dark-blood late gadolinium enhancement CMR improves detection of papillary muscle fibrosis in patients with mitral valve prolapse

PurposePapillary muscle fibrosis may act as an arrhythmogenic substrate in patients with mitral valve prolapse (MVP). Previous studies used conventional bright-blood late gadolinium enhancement cardiovascular magnetic resonance (LGE CMR) imaging to assess papillary muscle fibrosis, although this technique suffers from poor scar-to-blood contrast which may limit its sensitivity, in contrast to dark-blood LGE. This study sought to compare bright-blood and dark-blood LGE for the detection of papillary muscle fibrosis in patients with MVP. Method60 patients with known isolated MVP referred for CMR were prospectively recruited. A routine CMR protocol was used to obtain cine imaging, dark-blood LGE and bright-blood LGE in three long-axis views and a stack of short-axis views. Flow mapping of the proximal aorta was performed to calculate mitral regurgitant volume. Images were analysed for cardiac volumes, ejection fraction, mitral regurgitation severity, MVP characteristics (mitral annular disjunction, prolapse volume) and presence of LGE at the papillary muscles and myocardium. ResultsDark-blood LGE detected significantly more subjects with LGE at the papillary muscles than bright-blood LGE (35% vs 15%, p = 0.002). There was no difference between LGE techniques regarding myocardial (non-papillary muscle) fibrosis (present in 25% each). No statistical differences were observed between patients with or without LGE at the papillary muscles regarding demographics, clinical data (including ventricular arrhythmia) and MVP characteristics. Furthermore, no association was found between LGE at the papillary muscles and at the myocardium. ConclusionsCompared to bright-blood LGE, dark-blood LGE CMR improves the detection of LGE at the papillary muscles in patients with MVP.

553 Myocarditis after COVID-19 vaccination—a case series

Myocarditis has been recognized as a rare complication of SARS-CoV-2 infection even in the absence of lung involvement and recent histological findings suggest that COVID-19-related myocardial damage may differ from other typical lymphocytic myocarditis associated with other viruses and could be possibly linked to diffuse infiltration of monocytes and macrophage leading to microvascular dysfunction and cell necrosis. SARS-CoV-2 vaccines have been well tolerated and associated with decreasing burden of disease in areas with high vaccination rates. Minor side-effects have been frequently described, mainly after second dose. Here, we report our findings in four male patients consistent with acute myocarditis at our Institutional Hospital; all four had recently received a second-dose mRNA vaccine. All presented with acute chest pain associated with biomarker evidence of myocardial injury and were hospitalized. None of them had a previous history of SARS-CoV2 infection. All of them showed markedly abnormal EKG findings with diffuse ST segment elevation and laboratory tests revealed elevated high-sensitivity (hs) troponin T levels and C-reactive protein with no peripheral eosinophilia. All patients underwent nasopharyngeal swabbing and the specimens were tested for common respiratory viruses by RT-PCR and resulted all negative. All patients underwent CMR scan during hospitalization. The hospital course was benign for all patients without evidence of arrhythmias or heart failure, in all cases we performed a conservative treatment with nonsteroidal anti-inflammatory drugs and colchicine with progressive normalization of troponin levels before discharge. Our cases presented features of acute myocarditis with a temporal association with the mRNA Covid-19 vaccination, in absence of other apparent causes (in fact none had viral prodromes) nor COVID-19 infection in the prior year. Several reports in the past months had suggested a possible association between the mRNA Covid-19 and myocarditis, most of the cases presenting in young males, after the second dose and with a favourable course. Thus, given the potential risk of cardiac involvement after SARS-CoV-2 infection even in younger adults, the risk-benefit decisions favours vaccination for population immunity. Despite this, the potential mechanisms of SARS-CoV-2 vaccine-related myocarditis seem different from the previously described eosinophilic myocarditis after smallpox vaccination remain unclear and vaccine adverse event reporting remains of high importance. Figure 1 shows one acute MRI scan with STIR, T2-map and LGE in short-axis and apical four-chamber view.

453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Abstract Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Acute Limited Intimal Tear of the Right Aortic Sinus.

HomeRadiology: Cardiothoracic ImagingVol. 3, No. 6 Previous Images in Cardiothoracic ImagingFree AccessVascular ImagingAcute Limited Intimal Tear of the Right Aortic SinusLucas de Pádua Gomes de Farias , Márcio Campos Sampaio, José Honório de Almeida Palma da Fonseca, Luciana de Pádua Silva BaptistaLucas de Pádua Gomes de Farias , Márcio Campos Sampaio, José Honório de Almeida Palma da Fonseca, Luciana de Pádua Silva BaptistaAuthor AffiliationsFrom the UnitedHealth Group Brazil, Hospital Samaritano Paulista, Avenida Brigadeiro Luís Antônio 1895, Bela Vista, São Paulo, SP 01317-002, Brazil.Address correspondence to L.d.P.G.d.F. (e-mail: [email protected]).Lucas de Pádua Gomes de Farias Márcio Campos SampaioJosé Honório de Almeida Palma da FonsecaLuciana de Pádua Silva BaptistaPublished Online:Dec 2 2021https://doi.org/10.1148/ryct.210239MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Limited intimal tears (LITs) are uncommon but potentially lethal lesions within the dissection spectrum, occurring in approximately 5% of patients presenting with acute aortic syndrome (1). LITs are classified as a “class 3 of intimal tear” and represented by intimomedial tears with an eccentric aortic wall bulge but without substantial hematoma (2). While the edges of an LIT can be undermined to a variable degree and filled with small amounts of blood or clot, there is no propagation of the dissection plane along the aorta and no exit tear and double-barrel flow channel as in classic aortic dissection (1,3). LITs may evade identification at transesophageal echocardiography or CT because of the limited extent of undermined intimal layers and a minimal amount of blood in the dissected aortic wall. This imaging pitfall can result in progression of dissection, cardiac tamponade, or aortic rupture causing potentially lethal outcomes (1,2,4). Furthermore, the diagnosis of LITs may be missed if conventional diagnostic criteria that are dependent on the presence of an intimal flap are applied (4). Awareness of this entity, high index of suspicion at CT angiography with use of appropriate reconstruction techniques for the aortic root may allow timely patient management (1) (Figure).Images in a 62-year-old man who presented to the emergency department with acute chest pain. (A) Short-axis view of the aortic root, (B) three-chamber view, (C–E) three-dimensional volume-rendered images, and (F) intraoperative view after median sternotomy with extracorporeal circulation show an eccentric bulge of the right aortic sinus (R) with the presence of a focal limited tear (arrowhead). This is represented by focal linear “flaps” with undermined edges, as a bandlike outpouching where the right coronary artery (RCA) took off. The patient underwent graft replacement of the ascending aorta and aortic valve replacement. AA = ascending aorta, LA = left atrium, LV = left ventricle, LM = left main artery, R/L/NC = right/left/noncoronary aortic sinus.Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: L.d.P.G.d.F. No relevant relationships. M.C.S. No relevant relationships. J.H.d.A.P.d.F. No relevant relationships. L.d.P.S.B. No relevant relationships.Keywords: CT Angiography, Vascular, Aortic RootAuthors declared no funding for this work.

OR4. Agreement between Transthoracic Echocardiography and Surgical Measurements of the Tricuspid Annulus Diameter

Abstract Aims The tricuspid annulus dilatation is an indication for tricuspid repair concomitant with mitral surgery. The distance between anteroseptal and anteroposterior commissure represents the direction of dilatation provided by surgical measurements. However, none of the standard views of two-dimensional transthoracic echocardiography (2D-TTE) intersect that plane and there is still a lack of study regarding the tricuspid annulus measurements by three-dimensional transthoracic echocardiography (3D-TTE). Therefore, this study aims to determine the agreement between the tricuspid annulus diameter measurement by transthoracic echocardiography and surgical measurement. Methods and Results 40 patients were included. Measurements of tricuspid annulus diameter by 2D-TTE and 3D-TTE were performed before surgery in parasternal right ventricle inflow (PRVI), parasternal short axis (PSAX), apical 4-chambers (A4C), and multiplanar analysis 3D-TTE views. Surgical measurements were performed during surgery. Agreement between the echocardiography and surgical measurements was analyzed using Bland-Altman and intraclass correlation analysis. Mean difference ± standard deviation (limits of agreement) and ICC of PRVI 2D-TTE vs surgical measurement were 1.35±5.02 mm (-8.48 - 11.18 mm), ICC 0.89, p < 0.001; PSAX 2D-TTE vs surgical measurement were 1.35±5.23 mm (-8.90 - 11.60 mm), ICC 0.88, p < 0.001; A4C 2D-TTE vs surgical measurement were 1.33±3.69 mm (-5.91 - 8.56 mm), ICC 0.93, p < 0.001; septolateral diameter 3D-TTE vs surgical measurements were 1.42±4.41 mm, (-7.22 - 10.06 mm), ICC 0.90, p < 0.001; anteroposterior diameter 3D-TTE vs surgical measurements were -2.695±7.43 mm (- 17.26 - 11.87 mm), ICC 0.68, p < 0.001. Conclusion A4C 2D-TTE and septolateral diameter 3D-TTE measurement have an excellent agreement with surgical measurement.

Abstract 9479: Novel Predictors of Left Ventricular Reverse Remodeling in Patients With Recent-onset Dilated Cardiomyopathy Using T1 and T2 Mapping on Cardiac Magnetic Resonance

Introduction: The prognosis of patients with idiopathic dilated cardiomyopathy (DCM) has improved in recent decades with guideline-directed medical therapy. There is an essential need for better biomarkers to predict left ventricular reverse remodeling (LVRR) in DCM. Native T1, T2 and left ventricular (LV) global strain by cardiac magnetic resonance (CMR) without contrast agents provides a novel quantitative method for myocardial tissue characterization. Hypothesis: CMR parameters predict LVRR in patients with DCM. Methods: A total 34 patients ( 58 ± 13 years, 25 male) with DCM underwent baseline CMR imaging (3T Philips), including cine, late gadolinium enhancement (LGE) CMR, and triple-slice T1 and T2 mapping (short modified look locker inversion recovery ShMOLLI sequence). The 6SD-LGE (% area), global circumferential strain (GCS), global radial strain (GRS), global longitudinal strain (GLS), global radial strain (GRS), LV mass index (LVMI), LV end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (EF) were calculated from multiple short-axis views. Echocardiography was conducted before and > 1 year after after optimal medical therapy. Results: The patients were divided into two groups, LVRR with LVEF increase of >10% and the final value of ≥40% for those without. There were no significant differences in LV mass index, LVEDV, LVESV, and LVEF between the two groups (80 ± 20 g/m 2 vs 78 ± 19 g/m 2 ; 174 ± 54 ml vs 165 ± 48 ml; 134 ± 51 ml vs 122 ± 46 ml; 24 ± 9% vs 28 ± 9%, respectively). The any LV global strain showed no significant difference between the two groups. The 6SD-LGE, native T1, and T2 values were significantly lower in LVRR+ group than in LVRR-group (15.3 ± 15.5 % vs 5.9 ± 6.8%;1376 ± 59 ms vs 1301 ± 42 ms;55 ± 3.5 ms vs 50 ± 2.5 ms,respectively). The LGE-6SD < 13%. native T1 value < 1330 ms and T2 values < 53ms were the best threshold values for predicting LVRR (The LGE-6SD: sensitivity, 82%; specificity, 41%; AUC 0.72, T1:sensitivity, 82%; specificity, 71%; AUC 0.87, and T2: sensitivity, 82%; specificity, 63%; AUC 0.88). Conclusions: Native T1 and T2 mapping values may be useful for assessing of the LVRR in patients with DCM even without contrast.

Abstract 14321: A Validation Study of Myocardial Elastography Against Coronary Computed Tomography Angiography in Patients With Coronary Artery Disease

Introduction: Myocardial Elastography (ME) is a new quantitative strain imaging method capable of detecting ischemia due to Coronary Artery Disease (CAD). ME has been compared to nuclear perfusion imaging with good agreement. Coronary Computed Tomography Angiography (CCTA) has been shown to have superior accuracy to nuclear perfusion imaging for CAD staging. In this study, ME is compared to CCTA in CAD patients. Methods: High framerate (300 fps) echocardiography in five patients presented with chest pain or shortness of breath symptoms, or having prior history of CAD. Standard short-axis views were acquired at the mid-, basal, and apical left-ventricular (LV) levels using a research ultrasound system (Vantage, Verasonics) with a phased array (P4-2, Philips). ME radial systolic strain (ε) was imaged to evaluate wall thickening using 2D cross-correlation and gradient-based methods on the raw (RF) signals. Average ε within each perfusion territory (LAD, RCA, LCX) was then computed N=45. CCTA was performed using an AcquilionOne Scanner (Canon) with Iohexol (Omnipaque, GE) for contrast. Echocardiograms were coregistered with CCTA using anatomical landmarks. Results: Good qualitative agreement between ε (ME) and stenosis level (CCTA) was obtained (Fig. 1A). ME was sensitive in detecting moderate to severe stenosis showing reduced ε. At mild stenosis, despite a trend of ε reduction, some territories maintained mechanical functionality, possibly due to collateral engagement, demonstrating that both structural (CCTA) and functional (ME) properties are complementary in informing on myocardial viability and functionality, especially at mild stenosis. Future work will entail incorporation of FFR CT measurements as an additional functional reference measurement to validate ME strain.

Patterns of Replacement Fibrosis in Hypertrophic Cardiomyopathy.

Background Myocardial replacement fibrosis is one of the major histologic features of hypertrophic cardiomyopathy (HCM), but its characteristics have not been well delineated. Purpose To clarify the characteristics of replacement fibrosis in HCM and to evaluate the prognostic value of the regional extent of fibrosis. Materials and Methods This prospective study evaluated participants with HCM who underwent contrast-enhanced cardiac MRI from March 2011 to April 2019. For each participant, global and 16-segment extent of late gadolinium enhancement (LGE) in the left ventricle (LV) at cardiac MRI was analyzed. The primary end point was all-cause death. Results Among the 798 study participants enrolled (median age, 49 years [interquartile range {IQR}: 38-59 years]; 508 men), 588 (74%) underwent whole-exome sequencing. Thirty-five participants (4%) experienced death from any cause during a median follow-up of 2.9 years (IQR: 1.5-4.7 years). Spearman analysis showed weak correlations between the extent of LGE and wall thickness (LGE of global LV and maximal LV wall thickness, r = 0.35 [P < .001]; LGE and thickness of septum, r = 0.30 [P < .001]). In the 16-segment model, the distribution of LGE was visually inhomogeneous and higher in the basal anterior, basal septal, midanterior, and midseptal regions (P < .001). This similar distribution of LGE was observed in participants with asymmetric septal hypertrophy, those with apical HCM, participants positive for mutation and those negative for mutation, and participants with MYH7 and MYBPC3 mutations. Cox analysis indicated that both the global extent of LGE (adjusted hazard ratio = 1.68 per 10% increase in LGE; P < .001) and the regional extent of LGE (ie, basal, midventricular, and apical regions of LV when on the short-axis view; septum, anterior free wall, inferior free wall, and lateral free wall when on the long-axis view) were associated with adverse outcomes. Conclusion In hypertrophic cardiomyopathy, myocardial replacement fibrosis weakly correlated with hypertrophy, was inhomogeneous and asymmetric, and was predominantly distributed in the interventricular septal wall and anterior free wall at the basal and mid levels. Greater extent of fibrosis was associated with poor prognosis, regardless of its location in the left ventricle. © RSNA, 2021 See also the editorial by Hanneman in this issue.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

Prenatal ultrasound diagnosis and management of fetal aortopulmonary septal defects: a case series

BackgroundTo investigate the prenatal ultrasound diagnosis and management of patients with aortopulmonary septal defects (APSDs).MethodsA total of 8 fetuses with APSDs who underwent fetal echocardiography at our hospital from January 2015 to January 2019 were retrospectively included in this study.ResultsAmong the 8 fetuses, there were 4 cases of type I APSD, 3 cases were type II, and 1 case was type III. Among the 8 cases, there were 2 cases of simple APSD. There were echocardiographic characteristics that were common to all 3 types of APSD. This included defects between the ascending aorta and the trunk of the pulmonary artery in the short-axis section of the aorta, and in the three vessels and the three-vessel trachea section. Furthermore, the “V”-shaped structure confluence point of all APSD cases was positioned more forward than normal in the three-vessel trachea section. Type I APSD can be better characterized by the cross-section of the double outflow tract of the aorta and the pulmonary artery, which is close to the aortic valve and pulmonary valve. Type II APSD can be clearly diagnosed by the short-axis view of the aorta. Since the defect between the aorta and the pulmonary artery is distant from the aortic valve and pulmonary valve, the defect does not involve the bifurcation of the pulmonary artery and may be associated with an ectopic origin of the right pulmonary artery. Type III APSD is similar to a permanent arterial trunk, and the space between the ascending aorta and the trunk of the pulmonary artery is completely missing. Color and pulse Doppler showed shunt flow in the defects.ConclusionsAPSD can be diagnosed and classified by fetal echocardiography. This, together with the presence or absence of fetal intracardiac and extracardiac deformities, can provide valuable prenatal information to pregnant women and their families, which may facilitate timely diagnosis and timely surgical treatment after birth.

Echocardiographic assessment of radial right ventricular function in heart transplant recipients.

AimsRight ventricular (RV) allograft dysfunction is present in half of all heart transplant (HT) recipients. Non‐invasive assessment of RV function in the setting of rejection is not well described. We outline an echocardiographic technique, short‐axis fractional area change (SAXFAC), to evaluate RV function in the HT population and correlate this with the grade of pathologic rejection.Methods and resultsWe retrospectively reviewed the electronic medical records of 110 people who received a HT between 1 January 2015 and 29 February 2020 and had no evidence of rejection. One hundred eighty‐two transthoracic echocardiograms (TTEs) completed up to 1 year from the date of transplantation were analysed for the target acoustic window, the parasternal mid‐ventricular short‐axis view. Sixty‐one TTEs from 23 healthy transplants were deemed appropriate for SAXFAC determination. Thirty‐three organ recipients with at least grade 1R allograft rejection were also identified, and their TTEs screened for SAXFAC analysis. Two expert readers independently calculated SAXFAC as follows: RV end‐diastolic area minus end‐systolic area divided by end‐diastolic area. Using commercially available software (Epsilon, Ann Arbor, Michigan), we quantified RV radial strain, longitudinal strain, and apical fractional area change (FAC). Twenty‐eight transplant recipients with grade 0R or 1R rejection and nine patients with clinically significant rejection completed the study analysis. SAXFAC demonstrated significant variability in the entire population with an inverse relationship to severity of allograft rejection (P ≤ 0.01). Radial strain and FAC were also associated with clinically significant rejection (P ≤ 0.01).ConclusionsShort‐axis fractional area change is a simple two‐dimensional technique to assess RV function in HT recipients and showed no significant inter‐observer variability. In our small, single‐centre, retrospective case series, lower SAXFAC values were associated with clinically significant allograft rejection. The small sample size and infrequent occurrence of rejection make our observations hypothesis‐generating only. We advocate dedicated RV SAXFAC imaging planes be included when assessing allograft function.

A Woman With Painful Elbow

A 71-year-old woman presented to the emergency department with right elbow pain after a fall. On physical examination, she was conscious and had pain well-localized to the posterior aspect of the elbow without any open wounds or swelling. She was unable to extend her elbow. Other physical examinations were unremarkable. Radiography (Figure 1) and point-of-care ultrasound of the right elbow were performed (Figure 2, Figure 3, Video).Figure 2Point-of-care ultrasound (short-axis view) of the olecranon fossa demonstrating 3 different echogenic bands within the joint fluid, separating into fatty material (arrowhead), serous joint effusion (anechoic collection), and sediment of red blood cells (asterisk). This trilevel appearance of lipohemarthrosis is called the “parfait sign.” O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Point-of-care ultrasound (long-axis view) along the sagittal plane showing an elevated posterior fat pad sign (arrowhead) with heterogeneous echotexture consistent with lipohemarthrosis in the olecranon fossa. O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Occult olecranon fracture with elevated posterior fat pad sign and lipohemarthrosis. Point-of-care ultrasound of the right elbow demonstrated an elevated posterior fat pad sign with lipohemarthrosis. Occult olecranon fracture was diagnosed by computed tomography (Figure 4). The patient was discharged with a splint and started rehabilitation on a 1-week follow-up. Geriatric elbow fractures are not uncommon in the ED after low-energy falls. Diagnosis can sometimes be difficult with radiography because of overlapping bones or inappropriate radiographic positions. Point-of-care ultrasound is an ideal and practical tool for rapidly evaluating traumatic elbow injury.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Findings of elevated posterior fat pad sign and lipohemarthrosis on point-of-care ultrasound are highly sensitive predictors of intraarticular elbow fractures.2O'Dwyer H. O'Sullivan P. Fitzgerald D. et al.The fat pad sign following elbow trauma in adults: its usefulness and reliability in suspecting occult fracture.J Comput Assist Tomogr. 2004; 28: 562-565Crossref PubMed Scopus (47) Google Scholar, 3Rabiner J.E. Khine H. Avner J.R. et al.Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children.Ann Emerg Med. 2013; 61: 9-17Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Costa D.N. Cavalcanti C.F. Sernik R.A. Sonographic and CT findings in lipohemarthrosis.AJR Am J Roentgenol. 2007; 188: W389Crossref PubMed Scopus (12) Google Scholar Lipohemarthrosis is defined as “2 or 3 different echogenic bands seen within the joint fluid,” separating into fatty material, serous joint effusion, and sediment of red blood cells.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This trilevel appearance is sometimes called the “parfait sign.” Treatment of nondisplaced elbow fractures involves immobilization for a duration of 1 week. https://www.annemergmed.com/cms/asset/2b8d4b36-a95f-43b2-8942-70edc14a2430/mmc1.mp4Loading ... Download .mp4 (0.86 MB) Help with .mp4 files VideoPoint-of-care ultrasound (short-axis view) of the right elbow revealing a trilevel area of joint fluid within the olecranon fossa, known as lipohemarthrosis (asterisk) (visible from 00:00 to 00:04); long-axis view in the same region presented an elevated posterior fat pad sign (arrowhead) (visible from 00:04 to 00:09).

Training- and sex related alterations of global feature-tracking strain values of highly trained athletes using cardiac magnetic resonance imaging

Abstract Introduction Cardiac magnetic resonance imaging (CMR) is a reference method for assessing the morphological and functional parameters of the heart, and more recently, strain analysis can detect mechanical features. Based on echocardiographic data, strain parameters may help to differentiate between physiological athlete adaptation and pathological hypertrophy, however, there are still little data available among elite athletes regarding strain values using CMR. Aims Our aim was to study the strain characteristics of the athlete's heart using CMR imaging. Methods Overall, 228 (149 male, 24±5 years) highly trained adult (18–35 years), Caucasian athletes (≥10h training hours/ week) who underwent CMR examination as part of their screening were included in our study. Cine movie images in long- and short axis views were performed. Standard CMR parameters including left- and right ventricular (LV and RV) volumes, ejection fraction and muscle masses were measured. Feature-tracking strain analyses were performed, global LV longitudinal, circumferential and radial strain and RV longitudinal strain were calculated. CMR parameters of athletes were compared with healthy sex- and age matched sedentary control groups (n=105, 55 men). Results Athletes competed in mixed (n=99), endurance (n=99) and power (n=30) sport disciplines, and performed sport activity in quite high training hours (average: 21±5 hours/week). Regarding standard CMR parameters we found pronounced sports adaptation in both male and female athletes compared to sex- and age matched controls including lower LV and RV ejection fraction (p&amp;lt;0.05), elevated LV and RV volumes and masses (p&amp;lt;0.001). Strain analysis also revealed differences between athletes and controls: LV- GLS, GCS, GRS were lower in athletes compared to controls, regardless of their sex (p&amp;lt;0.05). RV-GLS was slightly lower in male athletes compared to male controls. Examining the effects of sport disciplines, we found the most marked sport adaptation in the case of endurance athletes. Training hours showed a positive correlation with LV-GLS and GCS values, and a negative correlation with GRS (p&amp;lt;0.001). We found that male athletes had more pronounced cardiac adaptation compared to females (p&amp;lt;0.001), and their LV-GLS and GRS values were lower (GLS: male athletes: −20±2% vs. female athletes: −22±2%; p&amp;lt;0.001), while GCS and RV-GLS showed no difference between sexes. Conclusion Our results suggest that in addition to standard CMR parameters, global strain values also show a small but consistent change during sport adaptation. Moreover, our results support the use of sex specific strain normal values in highly trained athletes. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by the Research Excellence Programme of the Ministry for Innovation and Technology in Hungary within the framework of the Bioimaging Thematic Programme of Semmelweis University. LS was supported by the ÚNKP-20-3-II-SE-61 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund.

Evaluation of myocardial strain assessed by CMR tissue-tracking to predict adverse cardiovascular events in patients with cardiac amyloidosis

Abstract Background Cardiac affectation in amyloidosis is presented among 50% patients what implies worse prognostic. Early diagnosis and prognostic stratification is mandatory after the appearance of new therapies that could modify the course of the disease. Purpose The aim of our study was to assess the prognostic value of cardiac magnetic resonance parameters, including Tissue deformation, in cardiac amyloidosis patients. Methods We recruited patients (p) prospectively followed in our cardiomyopathy unit, for a mean period of 10 years (from 2010 to 2020) who were diagnosed with CA. Baseline clinical, laboratory and echocardiographic data were obtained. Contrast-enhanced CMR was performed on a 1.5 T clinical scanner. Routine analysis was performed with a semi-automatic software for volumetric analysis. When late gadolinium enhancement was present, percentage of area of enhancement (LGE) was calculated.All strain parameters were measured off-line using dedicated software. Left ventricular circumferential strain (CS) measurements were obtained using mid-ventricular level short-axis cine views. Longitudinal strain (LS) derived from cine SSFP of 2-, 3-, and 4-chamber long axis views.Finally we evaluated the CMR parameters related with the combined event of mortality and heart failure in the follow-up. Results A total of 98 p were included, with a mean age of 67.5±16.9 years old. Mean follow-up was 42,2±32 months. 22 p (24,4%) had light-chain amyloidosis (AL), 34 p (37,8%) wild type transthyretin amyloidosis (ATTRwt) and 34 p (37,8%) familiar transthyretin amyloidosis (ATTRm). 59p (60,8%) died or present heart failure during the follow-up. Patients who died or present heart failure in the follow-uo had lower left ventricular ejection fraction (48,25±12,2% vs 56,13±11,03%, p=0,003), higher myocardial mass (156,05±54,8g vs 120,84±56,1g, p=0,007), higher LGE (8,6±6,8% vs 4,4±2%), worst GLS (−14,76±6,1% vs −18,67±6,2%) and worst GCS (−23,3±9,7% vs −30,04±9,1%). Both, GLS and GCS were independently associated with the combined event of dead or heart failure when evaluated within a multivariate analysis in a Cox regression model, but GCS was the stronger predictor of events in the follow-up over other CMR parameters like LGE an myocardial mass (p&amp;lt;0,001). Tertile distribution for GCS identified subgroups with different adverse events, particularly for the lowest-risk tertile: GCS &amp;lt;−34%, who had a combinated event in 13,6% of cases, significantly lower than patients in the mid-risk tertile (41,5%) and highest-risk tertile (53,8%) (Log-rank p=0,02) Conclusion Mortality and appearance of heart failure in cardiac amyloid patients is high. The assessment of myocardial strain parameters by CMR tissue-tracking in this population is useful to predict adverse outcomes in the follow-up. Particularly, GCS, stratify patients in subgroups with different risk of events, with added value to classical CMR parameters. Funding Acknowledgement Type of funding sources: None. Death &amp; Heart Failure by GCS

A modified Dabestani-Mahan formula estimates a normal pulmonary artery systolic pressure: a single-center retrospective study

Abstract Background Pulmonary artery systolic pressure (PASP) is increasingly used as an important datapoint in clinical decision-making and prognostication even in specialties outside of cardiology. Estimation of PASP by Doppler quantification using tricuspid regurgitation (TR) peak velocity is commonly used and correlates well with invasive measurement by right heart catheterization. Further study of transthoracic echocardiogram (TTE) techniques to estimate PASP is needed to provide this datapoint in the absence of sufficient Doppler data for the TR peak velocity method. One technique using right ventricular outflow tract acceleration time (AT) to estimate mean pulmonary artery pressure (MPAP) has been proposed by Dabestani Et al. by the equation MPAP=90-(0.62x AT). Assuming a linear relationship between MPAP and PASP, as suggested by Chemla Et al. by MPAP=(0.61xPASP)+2, a modified formula PASP=145-AT could possibly estimate a normal PASP ≤25 mmHg. Purpose To examine if a modified Dabestani-Mahan formula PASP=145-AT can estimate a normal PASP ≤25 mmHg as calculated by the TR peak velocity method. Methods We queried the electronic medical record at our institution for a sample of 300 patients who had a TTE performed between 2017 and 2020. Each TTE was reviewed and PASP was estimated for each using the TR peak velocity method. A right atrial pressure of 3 mmHg, 8 mmHg, or 15 mmHg was used in the estimation based on inferior vena cava diameter and collapsibility in keeping with the 2015 American Society of Echocardiography guidelines. A short axis view of pulmonary flow using the pulse-waved Doppler sample volume over the transpulmonary valve jet was then reviewed. The time from onset of ejection to peak flow velocity was measured manually as AT in milliseconds using Change Healthcare Cardiology Web Software Package 14.1.1. The measured AT was averaged over three cardiac cycles. Patients with a heart rate between 60 and 100 beats per minute at time of TTE and with sufficient Doppler data to estimate PASP by TR peak velocity and to measure AT were included in a logistic regression analysis. Results 154 patients were included in the statistical analysis. Patients who had a right ventricular outflow tract acceleration time greater than 120 milliseconds, giving a PASP ≤25 mmHg by the modified formula PASP=145-AT, had a 36 times greater odds of having a PASP ≤25 mmHg by the TR peak velocity method (OR=36.0, 95% CI=10.36–125.12, p&amp;lt;0.001). Conclusion(s) Based on a single-center sample, a right ventricular outflow tract acceleration time greater than 120 milliseconds could be used to estimate a normal pulmonary artery systolic pressure less than or equal to 25 mmHg in the absence of sufficient Doppler data for the commonly used TR peak velocity method. Funding Acknowledgement Type of funding sources: None.

Lean or obese, the epicardial fat thickness is increased in diabetics of south India – is it a south Indian paradox?

Abstract Type 2 Diabetes Mellitus (T2DM) is considered a Coronary Artery Disease (CAD) risk equivalent (1) Increased epicardial fat (EFT) thickness is one hypothesis contributing to the disproportionate CV morbidity and mortality in T2DM (2). Studies have shown, EFT was higher in patients T2DM and high BMI compared to the non diabetic group. (3). The aim of our study was to determine if T2DM patients had an increased EFT thickness even when their BMI was normal or low and whether there was a relation between the T2DM duration and the EFT thickness. Study cohort consisted of 260 patients, who underwent coronary angiography (CAG) for suspected CAD. All patients underwent detailed history, examination, routine biochemistry, HBA1c, Anthropometric measurements such as weight, height, waist circumference and BMI. Transthoracic ECHO assessment of EFT was done one day prior to CAG using the ECHO unit with a 3.6MHz transducer. The EFT thickness was measured as the echo-free space between the myocardium and visceral pericardium on the right ventricular free wall in end-systole in the parasternal long and short-axis views for 3 cardiac cycles. CAG was performed in the fasting state, using the Judkins' technique, by the femoral or radial artery approach. The severity of CAD was assessed by modified Gensini scoring system. The collected data were analysed with IBM.SPSS statistics software. Of the 260 patients 90 (73.1%) were males and 70 (26.9%) were females. In this study, the average value for normal EFT was 5.2mm in the control group (HBA1c &amp;lt;7) and anything more than 6 was taken as abnormal. Patients were divided into 4 groups based on their HbA1c levels viz Group A (HbA1c &amp;lt;7), Group B (HbA1c 7–9), Group C (HbA1c 9.1–12) and Group D (HbA1c &amp;gt;12). The EFT increased with increasing HbA1c levels and the correlation was statistically significant P value 0.0005. There was no gender differences in EFT in our study. EFT was higher when the T2DM duration was &amp;gt;5 yrs which was statistically significant. p value 0.0005 (Table 1). There have been no reports of the correlation between the duration of DM and EFT in literature to the best of our knowledge.There was a strong correlation between HbA1c and EFT and the severity of the coronary lesions which was statistically significant. There was no correlation between the BMI and EFT or CAD (Figure 1) and the EFT was increased even in non obese diabetics. This may be due to the fact that EFT is a part of visceral obesity whereas BMI is a measure of generalised obesity. Our study showed a linear correlation between EFT thickness, HBA1c, duration of T2DM irrespective of BMI values confirming the recent thinking that regional fat depots such as EFT are of greater importance as a CAD risk factor than overall adiposity as was previously considered. ECHO measured EFT can be used to raise the clinical suspicion of CAD in asymptomatic diabetics and being non invasive can also be used for followup. Funding Acknowledgement Type of funding sources: None. Table 1. Relation of T2DM duration with EFTFigure 1. Relation of BMI to EFT

Hypermobility of ulnar nerve does not affect throwing performance (122)

Objectives:Ulnar nerve neuropathy around the elbow is a common pathology in throwing athletes, and occurs due to many factors including valgus elbow, and ulnar nerve hypermobility. For patients with ulnar nerve neuropathy, anterior transposition of the ulnar nerve is common procedures. Meanwhile, Ulnar nerve hypermobility has been reported to be present in 2% to 47% of asymptomatic individuals. However, no studies have investigated the rate of ulnar nerve hypermobility in throwing athletes, and the relationship between ulnar nerve mobility, and clinical symptom and throwing performance. This study was designed to classify the sonographic assessment for the mobility of the ulnar nerve compared to physical evaluation, and to determine whether ulnar nerve hypermobility is associated with clinical symptoms and throwing performance in baseball players. We investigated ulnar nerve hypermobility using ultrasound to evaluate the relationship between the ulnar nerve hypermobility and clinical sign including throwing performance in college baseball players.Methods:138 elbows in 69 college baseball players were examined. Each participant was queried regarding symptoms attributable to the ulnar nerve. In addition, structural measurements consisting of the tinel test and elbow flexion compression testing were examined. Sonographic examiners were, unaware of reported symptoms, independently performed a standardized examination of both elbows to assess ulnar nerve hypermobility. For sonographic assessment, the ultrasound probe was located at the medial condyle of the humerus to visualize the ulnar nerve in short-axis view in the extended elbow position. During extension to flexion of the elbow, the mobility of ulnar nerves was assessed, and categorized as stable, or hypermobile, which was further subclassified as subluxation, or dislocation (Figure 1A, 1B, 1C). Pared t-test was used to compare the mobility of the ulnar nerve between throwing and non-throwing sides. Fisher’s exact test was used to assess the relationship between physical exams and the mobility of the ulnar nerve. Values of p<0.05 were considered statistically significant.Results:Ulnar nerve hypermobility was identified in 54 (78.3%) of the 69 elbows in throwing side. Meanwhile, hypermobility was 53 (76.8%) in non-throwing side without significant difference, compared to non-throwing side. Elbows with nerve hypermobility did not experience a higher prevalence of subjective symptoms (snapping, pain, and tingling) than did elbows with stable nerves. Provocative physical examination testing for ulnar nerve irritability, however, showed consistent trends toward heightened irritability in hypermobile nerves (p = 0.04 to 0.16). Demographic data and anatomic measurements were similar between the subjects with stable nerves and those with hypermobile nerves. Additionally, all participants did not show decrease of throwing performance.Conclusions:Ulnar nerve hypermobility occurs in over half of the baseball players in throwing and non-throwing sides. Utilizing a standardized sonographic examination, a diagnosis of ulnar nerve hypermobility can be established with substantial interobserver reliability. In baseball players, ulnar nerve hypermobility does not appear to be associated with an increased symptomatology attributable to the ulnar nerve and throwing performance. Anterior transplantation of ulnar nerve may not be needed for baseball players with ulnar nerve neuropathy.

Cardiac Magnetic Resonance Imaging and Ventricular Tachycardias Involving the Sinuses of Valsalva in Patients With Nonischemic Cardiomyopathy

The goal of this study was to investigate the relationship between cardiac scar on late gadolinium enhancement cardiac resonance imaging (LGE-CMR) and the presence of ventricular tachycardia (VT) ablation target sites within the sinuses of Valsalva (SV). Patients with idiopathic dilated cardiomyopathy (IDCM) often have scarring involving the basal myocardium, including the SV, allowing targeting of VTs from within the SV. Forty-three consecutive patients with IDCM underwent a VT ablation procedure with pre-procedure LGE-CMR. Retrospectively, scar characteristics were compared between patients with and without VT target sites in the SV. The ratio between SV-related scarring and the total cardiac scarring was defined as the SV scar index: SV-related scarring/total cardiac scarring. VT target sites were identified in the SV in 22 (51%) of 43 patients. LGE-CMR identified peri-aortic scarring involving the SV in 34 patients (79%). Scarring extended to the septum in 26 patients, involved the lateral basal wall in 4, and both areas in 13 patients. Scar volume within the SV was larger in patients with SV-VT targets (1.7 ± 0.9cm3 vs. 0.7 ± 0.6cm3; p<0.0001) compared with other patients. A cutoff scar volume identifying SV-VT targets was 1.23cm3 in the short-axis view (area under the curve 0.82; sensitivity 0.64; specificity 0.91). The SV scar index was significantly greater in patients who had SV-VT target sites (0.33 ± 0.2 vs. 0.09 ± 0.09; p<0.0001). Patients with IDCM undergoing ablation of VT often have peri-aortic scarring visualized on LGE-CMR. Both the presence and the extent of scarring adjacent to the aortic annulus are associated with the presence of VT target sites within the SV.