OBJECTIVES Endomyocardial biopsy (EMB) is a diagnostic tool for evaluating various cardiac conditions, such as myocarditis and myocardial infiltrative diseases. It is also the gold standard screening technique for detecting allograft rejection after heart transplantation. Despite advances in noninvasive imaging modalities for myocardial tissue characterization, EMB is still necessary for making a definitive diagnosis and determining treatment for certain conditions. Herein, we report our recent experience using EMB and its diagnostic yield. METHODS AND RESULTS We retrospectively reviewed EMBs performed at our institution from March 2018 through March 2023. Clinical data, including patient characteristics, indication and diagnostic yield of EMB, and procedure-related complications, were collected. Histopathological findings of the biopsies were recorded and classified based on the degree to which they matched the clinical diagnosis and cardiac magnetic resonance imaging (CMR) findings. A total of 212 EMBs obtained in 178 consecutive patients were retrospectively analyzed, with 42 biopsies performed for allograft rejection surveillance (10 patients) and the remaining performed for presumptive diagnosis of acute myocarditis or unexplained cardiomyopathy. Among the non-heart transplant cases, 54.7% of EMBs provided a clear diagnosis. The most common diagnosis was myocarditis (69%), followed by cardiac amyloidosis (CA) (26%). EMB was also helpful in detecting several rare cardiac conditions, such as eosinophilic granulomatosis with polyangiitis (EGPA), Fabry disease, and cardiac sarcoidosis. In a cohort of 101 patients who underwent both CMR and EMB, the results were concordant in 66% of cases. However, in 24.7% of patients, EMB was able to identify pathological conditions where CMR results were inconclusive, highlighting its complementary role in determining an accurate diagnosis. No complications were reported in any of the 212 EMBs performed. CONCLUSIONS With advances in cardiac imaging modalities, EMB is not routinely indicated for the diagnosis of cardiomyopathy. However, EMB is still an important tool for diagnosing specific cardiac diseases and could be crucial for confirming the diagnosis. EMB is generally safe if performed at experienced centers. (c) 2024 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Purpose: To perform qualitative and quantitative evaluation of low-monoenergetic images (50 KeV) compared with conventional images (120 kVp) in pulmonary embolism (PE) studies and to determine the extent and clinical relevance of these differences as well as radiologists' preferences. Materials and Methods: One hundred fifty CT examinations for PE detection conducted on a single-source dual-energy CT were retrospectively evaluated. Attenuation, contrast-to-noise-ratio, and signal-to-noise-ratio were obtained in a total of 8 individual pulmonary arteries on each exam-including both central (450/1200=37.5%) and peripheral (750/1200=62.5%) locations. Results were compared between the conventional and low-monoenergetic images. For quality assessment, 41 images containing PE were presented side-by-side as pairs of slices in both conventional and monoenergetic modes and evaluated for ease in embolus detection by 9 radiologists: cardiothoracic specialists (3), noncardiothoracic specialists (3), and residents (3). Paired samples t tests, a-parametric Wilcoxon test, McNemar test, and kappa statistics were performed. Results: Monoenergetic images had an overall statistically significant increased average ratio of 2.09 to 2.26 (P<0.05) for each measured vessel attenuation, with an increase in signal-to-noise ratio (23.82 +/- 9.29 vs. 11.39 +/- 3.2) and contrast-to-noise ratio (17.17 +/- 6.7 vs 7.27 +/- 2.52) (P<0.05). Moreover, 10/150 (6%) of central pulmonary artery measurements considered suboptimal on conventional mode were considered diagnostic on the monoenergetic images (181 +/- 14.6 vs. 387.7 +/- 72.4 HU respectively, P<0.05). In the subjective evaluation, noncardiothoracic radiologists showed a preference towards low-monoenergetic images, whereas cardiothoracic radiologists did not (74.4% vs. 57.7%, respectively, P<0.05). Conclusions: The SNR and CNR increase on monoenergetic images may have clinical significance particularly in the setting of sub-optimal PE studies. Noncardiothoracic radiologists and residents prefer low monoenergetic images.

Purpose: To perform qualitative and quantitative evaluation of low-monoenergetic images (50 KeV) compared with conventional images (120 kVp) in pulmonary embolism (PE) studies and to determine the extent and clinical relevance of these differences as well as radiologists’ preferences. Materials and Methods: One hundred fifty CT examinations for PE detection conducted on a single-source dual-energy CT were retrospectively evaluated. Attenuation, contrast-to-noise-ratio, and signal-to-noise-ratio were obtained in a total of 8 individual pulmonary arteries on each exam—including both central (450/1200=37.5%) and peripheral (750/1200=62.5%) locations. Results were compared between the conventional and low-monoenergetic images. For quality assessment, 41 images containing PE were presented side-by-side as pairs of slices in both conventional and monoenergetic modes and evaluated for ease in embolus detection by 9 radiologists: cardiothoracic specialists (3), noncardiothoracic specialists (3), and residents (3). Paired samples t tests, a-parametric Wilcoxon test, McNemar test, and kappa statistics were performed. Results: Monoenergetic images had an overall statistically significant increased average ratio of 2.09 to 2.26 (P<0.05) for each measured vessel attenuation, with an increase in signal-to-noise ratio (23.82±9.29 vs. 11.39±3.2) and contrast-to-noise ratio (17.17±6.7 vs 7.27±2.52) (P<0.05). Moreover, 10/150 (6%) of central pulmonary artery measurements considered suboptimal on conventional mode were considered diagnostic on the monoenergetic images (181±14.6 vs. 387.7±72.4 HU respectively, P<0.05). In the subjective evaluation, noncardiothoracic radiologists showed a preference towards low-monoenergetic images, whereas cardiothoracic radiologists did not (74.4% vs. 57.7%, respectively, P<0.05). Conclusions: The SNR and CNR increase on monoenergetic images may have clinical significance particularly in the setting of sub-optimal PE studies. Noncardiothoracic radiologists and residents prefer low monoenergetic images.

We assessed the appropriateness of chest–abdominal–pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS). A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool. Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63

Cardiac lipomas, especially ones originating from the left ventricle, are extremely rare. They may be asymptomatic or may present with various non-specific symptoms. Herein, we report a case of a giant lipoma of the left ventricle, with frequent ventricular premature beats on electrocardiogram. An echocardiogram demonstrated a large hyperechoic mass occupying a significant portion of the left ventricle. We further describe the diagnostic workup utilizing multimodality cardiac imaging and treatment options. Cardiac MRI demonstrated fat suppression, and cardiac CT showed a homogenous low-attenuation mass suggesting lipomatous matter. The mass was subsequently surgically removed for pathology examination in order to rule out liposarcoma. Histopathology demonstrated mature adipocytes, entrapped myocytes with hypertrophy, and interstitial fibrosis foci confirming the diagnosis of lipoma.

AIMS To assess prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing trans-catheter valve implantation (TAVR). METHODS AND RESULTS CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (California, USA) and Tel Aviv Medical Center (Israel) between 2013-2016 were analyzed by an automatic 4-chamber volumetric software and grouped into quartiles according to their RVVI. Higher 1-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q1<59 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q4>83 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for 1-year mortality in concordance to RVVI; HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p<0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics only the upper 5th percentiles (RVVI>120 ml/m2) retained statistical significance (HR 2.82, 95% CI 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery. CONCLUSIONS Cardiac volumetric data by CCTA performed for procedural planning may help predict outcome in patients undergoing TAVR.

AIMS:The aim of this study was to assess the prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing transcatheter valve replacement (TAVR). METHODS AND RESULTS:CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (CA, USA) and Tel Aviv Medical Center (Israel) between 2013 and 2016 was analysed by an automatic four-chamber volumetric software and grouped into quartiles according to RVVI. Higher one-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q1 <59 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q4 >86 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for one-year mortality in concordance to RVVI: HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p<0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics, only the upper 5th percentiles (RVVI >120 ml/m2) retained statistical significance (HR 2.82, 95% CI: 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery. CONCLUSIONS:Cardiac volumetric data by CCTA performed for procedural planning may help to predict outcome in patients undergoing TAVR.

PURPOSE:Primary sarcoma of the heart is a rare but devastating tumor. Median survival with conventional treatment is 8-12 months. When resection is not feasible, patients often succumb to heart failure secondary to obstruction of blood flow, valve dysfunction, chamber compression or conduction abnormalities. Palliative treatment options include systemic chemotherapy and external beam irradiation. We herein describe a novel technique using endovascular brachytherapy, aiming at reducing tumor mass, alleviating right ventricular pressure overload and at the same time keeping the option of R0 resection viable.MATERIAL AND METHODS:A 35-year-old man was diagnosed with a non-resectable high-grade intimal sarcoma of the right ventricle (RV), main pulmonary artery (PA) and right PA. After three cycles of doxorubicin and ifosfamide, the patient's symptoms of right heart failure worsened. Imaging documented tumor progression and supra-systemic pulmonary artery pressure. Through a trans-femoral venous access, a brachytherapy sleeve was placed in the RV and main and right PA. A dose of 20 Gy was delivered over a period of ten minutes.RESULTS:The patient had an uneventful course and was discharged home 24 hours after the procedure. Ten months after brachytherapy, repeat imaging demonstrated a significant reduction in tumor volume and an increase in pulmonary artery cross-sectional area with a marked reduction of pulmonary artery pressure, leading to a complete resolution of heart failure symptoms.CONCLUSIONS:Endovascular brachytherapy is a novel, safe and effective therapeutic modality for non-resectable primary cardiac sarcomas either for palliation of obstruction, or tumor mass reduction to allow complete resection.

HomeCirculationVol. 138, No. 6Wide QRS Complex Tachycardia in a 68-Year-Old Man Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBWide QRS Complex Tachycardia in a 68-Year-Old Man Ilan Rabey, MD, Dotan Cohen, MD and Bernard Belhassen, MD Ilan RabeyIlan Rabey Department of Cardiology (I.R., B.B.) Tel Aviv Sourasky Medical Center. Sackler School of Medicine, Tel Aviv University, Israel (I.R., B.B.). Search for more papers by this author , Dotan CohenDotan Cohen Department of Radiology (D.C.) Search for more papers by this author and Bernard BelhassenBernard Belhassen Bernard Belhassen, MD, Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv 6423906, Israel. Email E-mail Address: [email protected] Department of Cardiology (I.R., B.B.) Tel Aviv Sourasky Medical Center. Sackler School of Medicine, Tel Aviv University, Israel (I.R., B.B.). Search for more papers by this author Originally published6 Aug 2018https://doi.org/10.1161/CIRCULATIONAHA.118.036319Circulation. 2018;138:642–645ECG ChallengeA 68-year-old white man was admitted to our hospital because of syncope that occurred after getting out of his car and taking a few steps. He denied feeling palpitations or chest pain before the event. There was no evidence of seizures, incontinence, or a postictal state.His medical history consisted of hypertension, hyperlipidemia, heavy smoking, depression, and a previous triggered pulmonary embolism for which he was treated with warfarin for several months. His medications comprised a selective serotonin reuptake inhibitor, amlodipine, valsartan, simvastatin, and aspirin. He denied any cardiological workup in the past.On questioning, he reported that his only brother (age 85 years) was apparently healthy but was hospitalized in our department 7 years earlier with no further medical information.At admission to the emergency department, the patient was conscious. His blood pressure was 84/67 mm Hg. There were no clinical signs of congestive heart failure. The ECG showed a wide QRS tachycardia at a rate of 210/min (Figure 1A). Intravenous boluses of adenosine (6–12 mg) did not affect the tachycardia. He then received a synchronized 200J DC shock that resulted in resumption of sinus rhythm (70/min) with narrow QRS complexes and 2-mm ST depressions and T-wave inversions in the inferior and precordial leads V3 through V6 (Figure 1B). Laboratory tests revealed an increase in serum levels of troponin I (17 μg/L, n=0.00–0.05), creatinine (4.5 mg/dL, n=0.7–1.3), and creatine phosphokinase (502 μg/L, n=38–174). The results of other standard blood tests were normal.Download figureDownload PowerPointFigure 1. A, Spontaneous wide QRS tachycardia recorded at patient’s hospital admission, and (B) ECG recorded after direct current cardioversion.After he was admitted to the intensive coronary care unit, an echocardiogram was performed and the patient was treated with fluids, dual antiplatelet therapy, and anticoagulation. A few days after admission, on improvement of renal function, he underwent a coronary angiography and MRI.What is the diagnosis of the wide QRS tachycardia and what could be its anatomic origin and etiology?Please turn the page to read the diagnosis.Response to the ECG ChallengeDiagnosis of the TachycardiaThe diagnosis of ventricular tachycardia (VT) is made based on the following morphological criteria1: (1) regular, wide tachycardia having a right QRS axis (+150°); (2) typical rabbit-ear sign in lead V1 (R taller than R′) preceded by a small q wave along with rS pattern and r/S ratio <1 in lead V6 and R wave peak time in lead II >50 ms; and (3) the narrow QRS complexes in sinus rhythm with no evidence of ventricular preexcitation.Site of VT OriginThe morphology and axis of the QRS complexes during VT suggests an origin (exit point) of the tachycardia in the left ventricular (LV) anterolateral area.Etiology of the VTThere are several possible causes that should be considered.1. Ischemic heart disease should be discussed first because of its high prevalence in the elderly population and the multiple risk factors of ischemic heart disease present in our patient.This diagnosis is, however, unlikely because of the lack of previous cardiac history and the normal coronary angiogram.2. Cardiomyopathy (dilated, hypertrophic, and LV noncompaction) is also unlikely based on the results of the echocardiogram showing normal biventricular size and contraction without cardiac hypertrophy, along with the lack of abnormal trabeculations.3. An idiopathic VT originating close to the left anterior fascicle is a possible diagnosis based on the QRS pattern of the VT (right bundle-branch block and right axis) and the normal LV function.4. The diagnostic clue was provided from the review of the brother’s medical history showing that the latter experienced a sustained VT with a left bundle-branch block pattern2 (Figure 2). A diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) was made in the brother2 after an MRI demonstrated high signal intensity consistent with fatty replacement of the basal right ventricular free wall of the myocardium along with a few microaneurysms in the free wall with a normal LV. In our present case, MRI showed thinning of the LV anterolateral wall with akinesia, and subendocardial and transmural late gadolinium enhancement, as well (Figure 3). The right ventricle had normal systolic function with suspected mild dyskinesia at the outflow tract area and a few microaneurysms at the free wall.Download figureDownload PowerPointFigure 2. Spontaneous ventricular tachycardia recorded at hospital admission of patient’s older brother 7 years previously. ECG initially published by Belhassen et al.2 Reproduced from Belhassen et al2 with permission of the publisher. Copyright © 2014 Israel Medical Association Journal.Download figureDownload PowerPointFigure 3. Cardiac MRI findings. Anterior LV wall thinning seen on short-axis SSFP sequence (A) and transmural late gadolinium enhancement in the anterior (B) and lateral (C) LV wall. LV indicates left ventricular; and SSFP, steady-state free precession.Hence, we hypothesized that left-dominant ARVC/D could explain the left VT in our patient.Sustained VT originating from the LV has been rarely reported in patients with ARVC/D despite the frequent involvement of LV in ARVC/D. Sen-Chowdhry et al3 reported data supporting a genetic association between left-dominant ARVC/D and classical right-sided ARVC/D. They showed that one-third of patients with genotyped ARVC/D with a left-dominant phenotype have a pathogenic mutation in the ARVC-related genes. Our 2 brothers were found to be carriers of a mutation in the desmosomal gene PKP2. This specific variant PKP2 c.1613G>A (p.Trp538*) has been categorized as pathogenic or likely pathogenic. Although phenotypic variations of predominant right ventricular and LV involvement have been shown to coexist in the same family,3 no similar familial case has been previously reported. The present case suggests that a diagnosis of left-dominant ARVC/D should be discussed in the presence of right bundle-branch block–VT.AcknowledgmentsGenetic testing was performed in the Comprehensive Genetic Arrhythmia Program at UCSF (N. Downs, J. Campagna, and M. Scheinman). The authors also thank Drs Milman and Michowitz for their invaluable help during the management of the patient.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circBernard Belhassen, MD, Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv 6423906, Israel. Email [email protected]comReferences1. Wellens HJ. Electrophysiology: ventricular tachycardia: diagnosis of broad QRS complex tachycardia.Heart. 2001; 86:579–585. doi: 10.1136/heart.86.5.579CrossrefMedlineGoogle Scholar2. Belhassen B, Viskin S, Aviram G. Arrhythmogenic right ventricular cardiomyopathy: an unusual possible cause of arrhythmia in a 78 year old man with a 40 year history of palpitations.Isr Med Assoc J. 2014; 16:385–387.MedlineGoogle Scholar3. Sen-Chowdhry S, Syrris P, Prasad SK, Hughes SE, Merrifield R, Ward D, Pennell DJ, McKenna WJ. Left-dominant arrhythmogenic cardiomyopathy: an under-recognized clinical entity.J Am Coll Cardiol. 2008; 52:2175–2187. doi: 10.1016/j.jacc.2008.09.019CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Belhassen B, Shmilovich H, Nof E, Milman A, D'Ascenzi F, Abela M, Melato G, Mukherjee R and Green P (2020) A case report of arrhythmogenic ventricular cardiomyopathy presenting with sustained ventricular tachycardia arising from the right and the left ventricles before structural changes are documented, European Heart Journal - Case Reports, 10.1093/ehjcr/ytz239, 4:1, (1-7), Online publication date: 1-Feb-2020. Naz M, Shah J, Khan M, Sharif M, Raza M and Damaševičius R (2021) From ECG signals to images: a transformation based approach for deep learning, PeerJ Computer Science, 10.7717/peerj-cs.386, 7, (e386) August 7, 2018Vol 138, Issue 6 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.036319PMID: 30354609 Originally publishedAugust 6, 2018 PDF download Advertisement SubjectsArrhythmiasCardiomyopathy

BackgroundPrevious echocardiographic studies have revealed an association between enlarged cardiac chamber volumes and elevated troponin concentrations. An automatic 4-chamber volumetric analysis tool was adopted to investigate this association in patients who underwent cardiac-gated computed tomography angiography (CCTA). HypothesisWe hypothesized that troponin concentration within the normal range correlates with cardiac chambers' volumes. MethodsSerum troponin was obtained from 157 ambulatory patients before undergoing CCTA for nonacute coronary artery evaluation. Volumes of the cardiac chambers and the left ventricular mass were automatically analyzed and indexed to body surface area. Patients with a troponin concentrations within the upper quartile (>0.007 ng/mL, n = 39) were compared to patients with a troponin concentrations within the 3 lower quartiles of troponin concentrations (0.007 ng/mL, n = 118). ResultsNone of the patients had a troponin concentration >0.05 ng/mL (the 99th percentile of the general population). There were no significant differences in baseline characteristics between the groups. There were significant correlations between troponin and ventricular volumes after adjustments for age and gender. In an analysis that included 107 patients without any known heart diseases, including those pathological findings in the current CCTA, there were significant correlations between troponin and the left and right ventricular volumes after adjustments for age, gender, and baseline characteristics (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 1.03-1.14, P = 0.002 and OR: 1.11, 95% CI: 1.04-1.19, P = 0.002; respectively). ConclusionsUsing the technology of automatic volumetric analysis in individuals undergoing CCTA, an association between larger right and left cardiac chambers and higher levels of troponin concentration was shown.

Objectives: To evaluate the association between very small left atria (VSLA) on nongated computed tomography pulmonary angiography (CTPA) and mortality in patients without pulmonary embolism (PE). Methods: Patients who underwent nongated CTPA between 2011 and 2015 in order to rule out PE, and had an echocardiogram within 24 h of the CTPA, were retrospectively identified. The left atrial volume of nongated CTPA was calculated using automatic 4-chamber volumetric analysis software. The association between the lowest 5th percentile of the left atrial volume index, referred to as the VSLA group, and mortality was investigated after adjustment for age, gender, background diseases, and laboratory values. Results: The study cohort included 241 patients. Patients with VSLA had a left atrial volume index <24 mL/m2 (n = 11). Demographics and background diseases did not differ between the study groups. The median follow-up was 22.7 months (IQR 0.03-54.3). VSLA was an independent predictor of mortality (HRadj = 3.6; 95% CI 1.46-8.87; p = 0.005), along with malignancy (HRadj = 2.28; 95% CI 1.32-3.93; p = 0.003) and lower hemoglobin (HRadj = 0.86; 95% CI 0.76-0.99; p = 0.032). Conclusions: Our findings suggest that VSLA on nongated CTPA may serve as a marker for mortality. The use of CTPA volumetric analysis can help risk stratification in patients with dyspnea and no PE.

BACKGROUND Delayed pulmonary artery (PA) perforation and tamponade caused by implantable left atrial appendage (LAA) closure devices has been reported in patients with dose proximity between these structures. The LAA and PA anatomic relationship (LAA-PA(ar)) has not been analyzed systematically.OBJECTIVE The purpose of this study was to identify LAA-PA(ar) variants potentially susceptible to this complication using cardiac gated computed tomography angiography.METHODS We studied 100 consecutive patients with atrial fibrillation undergoing cardiac-gated computed tomography angiography of the left atrium. The LAA-PA(ar) was classified into 3 types on the basis of the location, length, and thickness of the segment of contact between the PA and/or its branches and the LAA: type 1, no contact; type 2, contact involving the proximal LAA (defined as the proximal 15 mm extending into the LAA from its ostium, or the LAA proximal to the first major bend arising <15 mm from the ostium); and type 3, contact limited to the distal LAA.RESULTS LAA-PA(ar) types 1, 2, and 3 were present in 7 (7%), 28 (28%), and 65 (65%) patients, respectively. For LAA-PA(ar) type 2, the mean contact segment thickness and length were 0.6 +/- 0.3 and 18.1 +/- 10.6 mm, respectively. For LAA-PA(ar) type 3, the distance between the LAA orifice and the segment of contact was <30 mm in 52 patients (80%).CONCLUSION In this series, the LAA came in direct contact with the main PA in the majority of patients. Contact involved the proximal LAA (where the fixation components of most LAA closure devices are positioned) in 28% of patients, posing potential vulnerability to PA perforation.

Poster: ECR 2012 / C-0702 / Reflux of Contrast Medium into the Inferior Vena Cava on Computerized Tomographic Pulmonary Angiography Alerting for Cardiac Diseases by: G. Aviram , D. Cohen , A. Steinvil , S. Berliner, O. Rogowski; Tel-Aviv/IL

Reflux of contrast medium into the inferior vena cava (IVC) is often detected on computerized tomographic pulmonary angiogram. The potential clinical implications and associated diagnoses of this finding have not been established. We investigated the prevalence and significance of reflux of contrast medium into the IVC in a large cohort of patients evaluated for possible pulmonary embolism (PE) by computerized tomographic pulmonary angiography. We retrospectively reviewed 1,065 consecutive computerized tomographic pulmonary angiographic examinations performed from January 1, 2007 through January 7, 2008 for the presence of reflux. Degree of reflux into the IVC and hepatic veins was graded from 1 (none) to 6 (severe). Patients' charts were reviewed for diagnoses during the index hospitalization and for background diseases. These clinical data were correlated with the reflux grade. The final study included 967 computerized tomographic pulmonary angiographic scans of 367 men and 600 women (mean age 62 ± 20 years, range 17 to 103). Almost 1/2 (480, 49.6%) had grade 1, 310 (32.1%) had grades 2 to 3, and 177 (18.3%) had grades 4 to 6. Multivariate logistic regression found that pulmonary hypertension, history of congestive heart failure, chronic atrial fibrillation, and acute PE were associated with extensive reflux (grades 4 to 6) with odds ratios (95% confidence intervals) of 5.4 (3.0 to 9.9, p <0.001), 3.7 (2.3 to 6.1, p <0.001), 2.3 (1.0 to 5.3, p = 0.044), and 1.8 (1.2 to 2.9, p = 0.011), respectively. Interobserver agreement between the 2 readers for reflux grading was good (kappa = 0.77). In conclusion, extensive reflux of contrast medium into the IVC detected on computerized tomographic pulmonary angiogram may serve as a pathophysiologic marker of right heart dysfunction, specifically pulmonary hypertension, congestive heart failure, chronic atrial fibrillation, or PE.