A 83-year-old man with hypertensive cardiomyopathy with left ventricular dysfunction diagnosed 5 years before (without coronary artery disease) in permanent atrial fibrillation since 8 years, was admitted to the ER for heart failure. He was not in anticoagulation therapy because contraindication for the presence of cerebral venous angiomas found several years before. An urgent ultrasound scan was performed that showed bilateral intra-atrial masses. UFH was started. The echocardiography(Fig. 1 panel A)show within the left atrium an isoechoic, not pedunculated mass, 8x5 cm, with lobulated margins, attached to the anterior wall and left atrial appendage, and expanding in the atrial cavity. Within the right atrium a smaller mass with the same characteristics was attached to the anterior wall, 4 x 3 cm (Fig. 1 panel B). TEE confirmed these characteristics and showed also vacuolated aspects inside the masses (Fig. 1 panel C). MDCT was then performed, the atrial masses appeared morphologically very similar to atrial myxomas, but they didn’t enhance iodine contrast agent resembling a typical thrombus behavior (Fig. 1 Panel D). No systemic emboli nor extracardiac tumors were found. CMR could not be performed due to patient claustrophobia. Considering intra-atrial thrombi as a main hypothesis, the treatment with UFH was continued and the masses were monitored by TTE. However, after more than one week the masses volume did not change. A contrast echocardiography with IV Sonovue was performed. A mild contrast enhancement of left atrial mass was seen, thus suggesting the diagnostic hypothesis of cardiac tumor (Fig. 1 Panel E). In this context we decided to perform transvenous biopsy of right atrial mass under intracardiac echocardiography guidance. The biopsy samples from the outer wall of the right atrial mass showed thrombotic features. After a long discussion in heart team, patient underwent to surgical resection of the masses through atrial approach and the surgical inspection was suggestive of neoplastic origin. The histological examination was performed showing thrombotic material with several phases of organization and mild aspects of neo-angiogenesis combined with mild lymphocyte infiltration and necrosis areas (Fig. 1 Panel F). We hypothesized that the histological features of the lesion, with the presence of vessel within the mass could explain the mild late contrast enhancement at Sonovue echocardiography simulating the features of cardiac tumor. In summary, in this case, despite a multimodal imaging approach, the nature of the bilateral intra-atrial masses could not be defined and the histological examination after surgical removal had a key diagnostic role showing organized thrombotic material. A proper differential diagnosis is extremely important in order to decide the appropriate treatment, but sometimes it is extremely challenging. Abstract 1111 Figure 1

Aims Lake Louise Criteria (LLC) are time-dependent and some acute myocarditis (AM) with preserved left ventricular ejection fraction (LVEF) could be missed, due to the limited accessibility of Cardiac Magnetic Resonance (CMR). We aimed to assess the potential value of cardiac strain measured by feature tracking (FT) imaging in this population. Methods and results Eighty-three patients with clinically suspected AM and normal LVEF were divided into 39 “confirmed AM” (positive LLC) and 44 “suspected AM” (negative LLC). An age and gender-matched sample of 42 normal subjects underwent CMR. In all groups, FT-derived biventricular strains and STE- global longitudinal strain (GLS) were assessed, being regularly measurable. Strain values < 5th percentile of the control group were considered abnormal. “Suspected” and “confirmed” AM were similar, except for medium time of CMR evaluation (5.2 vs 1 months from presentation, respectively; p = 0.004). Compared to healthy controls, both “suspected” and “confirmed” AM showed significantly impaired strain values. LV-global circumferential strain (GCS), right ventricular GCS and LV-GLS were abnormal in 15.4% and 15.9%, 20.5% and 15.9%, 7.7% and 9.1% in “confirmed” and “suspected” AM, respectively. STE analysis confirmed the results on LV-GLS, however a weak correlation emerged between STE and CMR-FT LV-GLS ( p = 0.08). Conclusions Compared to STE, CMR-FT analysis provided a more comprehensive and complementary biventricular strain evaluation that resulted similar in “confirmed” and “suspected” AM with normal LVEF. Conversely, mostly biventricular GCS was significantly reduced in up to 20% of patients, compared to healthy controls. Graphic abstract

Poster: "ECR 2017 / C-2538 / Investigation throught Angio-CT of Hybrid Coronary Artery Bypass" by: "M. Belgrano, M. Muca, B. Benussi, M. A. Cova; Trieste/IT"

A 42 years old woman was admitted to the Cardiology Department for heart failure. The woman had a diagnosis of Idiopathic Restrictive Cardiomyopathy.

A 75-year-old man was admitted to the E.R. for an anterior NSTEMI.

A 60 year old man was admitted to the E.R. for recurrence of transitory ischemic attacks. In order to exclude the presence of embolic sources a transesophageal echocardiography was performed which demonstrated an echo-free structure posteriorly to the aortic root, connected with the interatrial septum (Fig. 1 — A; online video 1). A continuous systo-diastolic flow inside the structure was evident at Color Doppler (Fig. 1 — B, online video 2), whereas the Continuous Doppler showed a high velocity systo-diastolic signal (>2.5 m/s; Fig. 1 — C) directed from the interatrial septum toward the right atrium. A coronary arterial–venous fistula (CAF) was suspected and the patient was referred for CT-angiography performed on a 256-slice multidetector CT scanner. CT showed an ectasic (9.5 mm) arterial–venous fistula with aneurysmatic origin from the left main artery (LMA) (Fig. 2 — A), slightly compressing the origin of the left circumflex artery (LC) (Fig. 2 — B) and draining in the right atrium (Adx) after a long and tortuous course posteriorly to the aortic wall (Fig. 2C). Unexpectedly, a narrow and tortuous anomalous left–right communication was also discovered, from the medial wall of the descending aorta on the right atrium (Fig. 2 — D). Fig. 2CT-angiography showing the ectasic CAF originating from the distal portion of the left main artery (LMA) (panel A; arrowheads) with an aneurysmal dilation (panel B; white arrows). The CAF, as shown at the Curved-plane reconstruction (panel C; white arrow), has a long and tortuous course posterior to the aortic wall, before draining in the right atrium (Adx). The narrow and tortuous conduct originating from the medial wall of descending aorta and terminating on the right atrium is also showed (panel D; red arrows). View Large Image Figure Viewer Download Hi-res image

Our aim was to evaluate the usefulness of computed tomography angiography (CTA) in vascular mapping for planning breast reconstruction after mastectomy using a free flap made with the deep inferior epigastric perforators (DIEP).

Purpose. The aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA).Materials and methods. The images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation.Results. No collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%).Conclusions. AA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.

PURPOSE:This study sought to assess the diagnostic accuracy of 64-slice computed tomography urography (CTU) in evaluation of the urinary tract.MATERIALS AND METHODS:A total of 322 CTU procedures were carried out in 317 consecutive patients (mean age 64.4 years). The findings were compared with previous and subsequent patient workup considering both laboratory and imaging studies, such as urine cytology, abdominal ultrasound and CT, cystoscopy, retrograde pyelography, surgery and pathology.RESULTS:Out of 322 CTU examinations, 169 showed significant urinary tract changes, whereas 153 revealed no urinary disease, in good agreement with the follow-up. In particular, in bladder evaluation, for which we have a direct comparison with cystoscopy in 125 patients, we calculated a CTU sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 85%, 94%, 92%, 89% and 90%, respectively.CONCLUSIONS:CTU was accurate for urinary tract evaluation, but it cannot replace cystoscopy in patients in whom a malignant bladder disease is suspected.

This study was done to analyse the costs of 64-slice computed tomography (CT) coronary angiography and conventional coronary angiography and determine the costeffectiveness of the two modalities.

The aim of this study was to correlate left main (LM) coronary artery dimensions with the presence of atherosclerosis by multidetector-row computed tomography (MDCT) coronary angiography (CA) and to assess coronary atherosclerotic plaques with a semiquantitative method.

This study compared the role of multislice computed tomography coronary angiography (MSCT-CA) and stress electrocardiography (ECG) in the diagnostic workup of patients with chronic chest pain.

This study sought to assess the role of multislice computed tomography (MSCT) in patients with suspected chronic mesenteric ischaemia (CMI).