The use of electrocardiographic-gated thoracic aortic computed tomographic angiography has become a routine clinico-radiological tool and has subsequently been incorporated into subspeciality national recommendations. Whilst the prevalence of acute aortic syndrome is relatively low, the same dataset provides the opportunity to identify the cause of the acute presentation, including coronary artery atheromatous disease and its consequences. Potentially life-threatening cardiac pathology continues to be overlooked and/or misinterpreted by radiologists despite being a required core competency. In the interest of minimising avoidable error and learning from previous errors, we aim to present some guidance for the general radiologist to assist in the image acquisition and interpretation of acute electrocardiographic -gated thoracic imaging.

This patient attended for pre-radio frequency ablation planning for drug refractory atrial fibrillation. The only abnormality demonstrated by transoesophageal echocardiography was a moderately dilated right atrium (RA). In our institution, 64-detector row computed tomography (CT) is now used as part of the pre-radio frequency ablation procedure. CT confirmed the transoesophageal echocardiography findings—normal …

Expanded extracellular volume (ECV) is an early marker of myocardial interstitial fibrosis in patients with hypertension. Animal studies suggest that surges in sympathetic nerve activity (SNA) might contribute more to the development of interstitial fibrosis than the resting level of SNA. The aim of this study was to investigate whether resting SNA or greater SNA reactivity to a stressor may be associated with expanded ECV in humans across a range of blood pressures. This was a cross-sectional study in 19 individuals with varying levels of ambulatory systolic blood pressure (111–153 mmHg, 48 ± 13 years, 26.5 ± 2.6 kg/m2, n = 10 diagnosed with hypertension and n = 9 normotensive controls). Beat-to-beat non-invasive blood pressure (Finometer), heart rate (3-lead ECG) and muscle SNA (MSNA; peroneal microneurography) were recorded simultaneously during baseline, and throughout a cold pressor test (physiological stress), with hand immersion in 3–4 °C water. LV chamber size, wall thickness and ECV were assessed using cardiac magnetic resonance imaging. Resting MSNA was not associated with cardiac ECV (B coefficient = − 0.07, 95

Adults with hypertension have higher prevalence of vertebral artery hypoplasia (VAH), which is associated with lower resting cerebral blood flow (CBF). We examined whether VAH impacts the ability to regulate CBF during haemodynamic stress when cardiac output and blood pressure are lowered via body negative pressure (LBNP). Participants underwent magnetic resonance angiography (MRA) at 1.5T during LBNP at 0, -20 and -40 mmHg, and were assigned to VAH (n = 13) or without-VAH (n = 11) groups post-acquisition. Phase-contrast MRA measured flow in the basilar artery (BA), internal carotid arteries (ICA), and the ascending aorta to measure cardiac output (CO). The CO decreased during all levels of LBNP in both groups (LBNP main effect P < 0.0001), whereas MAP was reduced in the group without VAH only (P = 0.0003). BA flow was reduced during LBNP in the group without VAH (P = 0.0267 at -20 mmHg and P < 0.0001 at -40 mmHg) but was surprisingly unchanged in the group with VAH (P > 0.05 all levels LBNP). ICA flow decreased during LBNP (P < 0.0001) and was not different between groups. Total CBF decreased during LBNP in hypertensives without VAH (P = 0.0192 at -20 mmHg and P < 0.0001 at -40 mmHg) but was unchanged in patients with VAH (P > 0.05 at all levels of LBNP). Total peripheral resistance (TPR) increased during LBNP in both groups, but the rise was greater in the group with VAH (-20 mmHg; P = 0.0129, -40 mmHg; P = 0.0016). In summary, hypertensive patients without VAH may tolerate decreases in CBF, whereas patients with VAH evoke a greater systemic TPR response to preserve CBF. KEY POINTS: Vertebral artery hypoplasia (VAH) is more common in hypertensive adults and is associated with lower resting cerebral blood flow (CBF), suggesting that VAH might impair the brain's ability to maintain cerebral blood flow during haemodynamic stress using lower body negative pressure. This study shows that hypertensive patients with VAH maintain CBF during body negative pressure, unlike those without VAH, who experience reductions in CBF. Patients with VAH show a greater rise in total peripheral resistance (TPR), suggesting a compensatory mechanism to maintain cerebral perfusion. The findings highlight that patients with VAH have an altered physiological response to hypovolaemia, where they may rely on systemic pressor responses to maintain perfusion of posterior brain territories in already hypoperfused circulation. This is important for understanding how VAH impacts cerebrovascular function in hypertensive patients and may influence clinical approaches to managing CBF in disease conditions.

The underlying aetiology and pathophysiology of arterial hypertension often remain unclear. To provide a better understanding of the disease process, a more comprehensive and multisystem use of magnetic resonance imaging is advocated in the assessment of hypertensive patients, with additional novel focus on the ‘selfish brain hypothesis’. This approach may guide more individualised therapy to managing one of the most important noncommunicable causes of human morbidity and mortality.

Caseous mitral annular calcification (CMAC), sometimes called liquefaction necrosis of mitral annular calcification (MAC), is a rare variant of MAC, a chronic degenerative process that progresses with age. It is a degenerative abnormality of the fibrous tissue and typically involves the posterior annulus, appearing as a smooth mass with no flow or acoustic shadow artefacts. It can be differentiated from other cardiac masses by CT and MRI. Whilst benign in nature, it is associated with a range of pathologies, such as mitral valve dysfunction, arrhythmias, and systemic embolisation. Given the risk of systemic embolisation, surgery may be appropriate, but there is no clear consensus in the literature in patients who are asymptomatic. This case highlights a case of CMAC presenting with a retinal artery occlusion, and was managed conservatively. Background The mitral annulus is a key component of the mitral valve, ensuring appropriate function by facilitating complete closure of the leaflets during systole. With age, MAC can occur, potentially resulting in mitral valve dysfunction, infective endocarditis, and arrhythmias. CMAC is a rare variant of MAC, typically involving the posterior annulus. Whilst benign, the risk of complications, such as systemic embolisation, may indicate a surgical approach to management, even in patients who are asymptomatic. Case Presentation A 60-year-old female, presenting with sudden loss of vision in the lower part of her left eye due to a branch retinal artery embolus, was admitted from ophthalmology services. An outpatient transthoracic echocardiogram showed an abnormal mass on the posterior annulus of the mitral valve. Transoesophageal echocardiography identified a calcified posterior aspect of the mitral annulus with normal leaflet mobility and trivial regurgitation, and an echogenic mass attached to the ventricular aspect of the mitral annulus (at the level of posteromedial commissure), 9x4 mm in size. A cardiac CT showed a caseous mitral valve with evidence of rupture of the calcified shell. Discussion with the surgical multidisciplinary team resulted in a conservative approach, with follow-up echo for monitoring. Conclusion Whilst a benign and rare variant of MAC, CMAC is associated with a range of pathologies, including mitral valve disease, arrhythmias, and systemic embolisation. Currently, there is no standardised management approach for CMAC. Surgery is currently recommended in the context of already known surgically indicated pathologies, such as severe mitral valve disease or systemic embolisation. However, this conservatively-managed patient has had no further complications with stable echocardiographic appearance on repeat echo 3 months following initial exam.

AIM: To compare the thoracic vascular opacification achieved using the standard bolus -tracking protocol (BTP) with a fixed-timing protocol (FTP) with a modified breathing in-struction during computed tomography pulmonary angiography (CTPA) examinations.MATERIALS AND METHODS: A single-centre review of CTPA examinations performed be-tween July 2018 and January 2019 using the BTP or FTP and weight-based contrast dosing of 20 mg iodine/kg body weight/s for 20 seconds at 100 kV tube potential. Radiodensity (in Hounsfield units) was analysed in the right ventricle, main pulmonary artery (MPA), left atrium, left ventricle, and ascending and descending thoracic aorta (DTA). A p-value of <0.05 was considered significant.RESULTS: Of 782 examinations, 88 BTP and 90 FTP examinations were included. Mean attenuation of the MPA was similar in the FTP (396 +/- 106 HU) and BTP (362 +/- 119 HU; p=0.06); however, good-quality (>= 250 HU) MPA opacification was achieved in more FTP ex-aminations (87/90, 96.7%) compared to the BTP (73/88, 82.9%; p=0.0 02). Mean attenuation of the DTA was better in the FTP (325 +/- 72 HU) than the BTP (228 +/- 75 HU; p <0.0001), with good-quality opacification (>= 250 HU) in 76/90 (84.4%) FTP examinations compared with 36/88 (40.9%) BTP examinations (p <0.001). CONCLUSION: The FTP achieves better opacification of the MPA and DTA compared to the BTP.(c) 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Postinfarct ventricular septal rupture is a serious complication in delayed or failed reperfusion with a grim prognosis. The optimal timing and treatment option remain debatable in the absence of randomized controlled trials. Percutaneous device closure is a well-reported and less invasive treatment option but recent imaging studies indicate that majority of defects are too large to be adequately covered by the currently Conformite Europeenne and Food and Drug Administration approved occluder devices.METHODS:Six patients presented with large and complex postinfarct ventricular septal ruptures, considered unsuitable for the Amplatzer post-infarct ventricular septal defect Occluder, so were treated using the prototype Occlutech® 36 mm PI-VSD occluder, including the first-in-human use.RESULTS:The prototype device was successfully deployed in all patients with satisfactory immediate results and shunt reduction. Three patients (50%) in cardiogenic shock did not survive beyond discharge, of which two were complicated by device dislodgement or embolization.CONCLUSIONS:Percutaneous closure of large postinfarct ventricular septal ruptures is possible using newer device with a wider coverage. Further device refinement is necessary to improve treatment outcomes.

AIMTo evaluate the detection of acute aortic syndrome (AAS) and the prevalence of alternative diagnoses that may explain the presentation or require follow-up.MATERIALS AND METHODSThis was a retrospective, blinded re-evaluation of consecutive electrocardiography (ECG)-gated computed tomography (CT) aortic studies by a cardiovascular radiologist performed between September 2019 and May 2020 in a tertiary-referral cardiothoracic centre.RESULTSThere were 118 identified examinations, six examinations were excluded leaving 112 (mean age = 61 ± 17; 56% male). Three cases of AAS were present (prevalence 2.7%); only one was reported on initial review. There were no false-positive diagnoses of AAS. The heart was mentioned in 79 (70.5%) reports and 73 (65.2%) of reviews revealed a total of 114 new observations; 111 (97.4%) of these were cardiovascular with 44/112 (39.3%) patients potentially having a significant previously unsuspected cardiovascular diagnosis.CONCLUSIONThe implementation of national clinical guidance to increase testing and improve image quality led to a series of challenges. The real value of ECG-gated CT may lie in detecting other diseases that mimic AAS. With the additional workload, increased subspecialty expertise is required but there needs to be a willingness to learn with an adequate support infrastructure.

Introduction The imaging standard in the diagnosis and grading of aortic stenosis is the echocardiogram. However, computed tomography (CT) offers a more anatomically precise measurement of the left ventricular outflow tract (LVOT) area and aortic valve (AoV) area. The purpose of this study was to compare the AoV area measured by echocardiogram and CT. Methods Data was prospectively collected on all patients undergoing CT for consideration of transcatheter aortic valve implantation (TAVI) from July 2019 - January 2020. Measurements of LVOT and AoV area were performed using validated software (TeraRecon, California). Echocardiographic measurements of the LVOT, peak velocity across the LVOT and the AoV were used to derive the AoV area using the continuity equation. Spearman correlation analysis was performed using R v3.3.3. Results There were 19 patients in whom contemporaneous echocardiography was available. CT derived AoV area was positively correlated with echocardiographic measurements of AoV area (rs=0.54, p= 0.02) and LVOT area (rs=0.58, p< 0.01). However, echocardiography led to an underestimation of both LVOT area and AoV area. 89% of the error in AoV area estimation at echocardiography was due to LVOT measurement error. The combination of echocardiographic measurements of velocity with CT derived LVOT area led to improved estimation of AoV area, (rs=0.75, p< 0.01). Conclusion The use of the continuity equation on echocardiography leads to underestimation of the AoV area. The combination of echocardiography and CT measurements makes the continuity equation estimate of CT area near the same as CT planimetry.

AIM:To assess the relationship of global longitudinal strain during left atrial (LA) and left ventricular (LV) filling and emptying.MATERIALS AND METHODS:Using magnetic resonance imaging in 47 hypertensive patients, biplane global LV longitudinal strain was evaluated and related to LA and LV filling and emptying (by volumetric analysis), and to pulmonary vein and trans-mitral flow (by phase-contrast imaging). The results were compared to normal subjects.RESULTS:In hypertensive patients, reduced global longitudinal LV strain was associated with reduced LA reservoir (47 ± 10 versus 53 ± 9%, p<0.05), reduced LA conduit function (21 ± 9 versus 32 ± 11%, p<0.004), reduced LA early peak emptying rate (150 ± 77 versus 230 ± 88 ml/s, p=0.007), and slower early LV filling (373 ± 141 versus 478 ± 141 ml/s, p=0.03). LA peak filling rate showed a positive correlation to LV peak emptying rate (R=0.331, p=0.02).CONCLUSION:In hypertensive heart disease, impaired LV longitudinal systolic function causes reduced LA filling and emptying, and this leads directly to impaired LV filling and diastolic dysfunction.

BackgroundThe functional implications of left ventricular (LV) morphological characterization in congenital heart disease (CHD) are not widely explored. This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV).MethodsA statistical shape modelling (SSM) framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) data in isolated CoA (n=25), CoA+BAV (n=30), isolated BAV (n=30), and age-matched healthy controls (n=25). Average 3D templates and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e. sphericity, conicity) or global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture was also explored.ResultsThe LV template was shorter and more spherical in CoA patient and LV sphericity was associated (p≤0.04) with lower global longitudinal, radial and circumferential strain, irrespective of the presence of aortic stenosis and/or regurgitation. Conversely, LV strain was not associated with arch architecture.ConclusionsDifferences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.

Arterial hypertension is a leading cause of mortality, affecting at least a quarter of the adult population, with its effects having devastating consequences to the global economy. Unfortunately, the underlying causes and pathophysiology of the disease often remain unclear. Ongoing research in this important field investigates the mechanisms involved in the genesis of hypertension. Magnetic resonance imaging is a well-established imaging technique that is widely used for anatomical organ and vascular evaluation. According to the latest European Society of Hypertension (ESC) guidelines, cardiovascular magnetic resonance can be used in the assessment of hypertensive patients. But the authors advocate a more comprehensive and multisystem use of the varied and novel sequences of MRI scanners to provide an even better understanding of the development of hypertension and its consequences. The extensive and detailed data that can be derived, with the additive focus on the concept of the ‘selfish brain hypothesis’, might further assist us in altering and providing a more individualised therapeutic approach to one of the greatest non-communicable causes of human mortality and morbidity.

Functional implications of left ventricular (LV) morphological characterization in congenital heart disease are not widely explored. This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV), and healthy controls. A statistical shape modelling framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) data in isolated CoA (n = 25), CoA + BAV (n = 30), isolated BAV (n = 30), and healthy controls (n = 25). Average 3D templates and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e., sphericity, conicity) or global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture was also explored. The LV template was shorter and more spherical in CoA patients. Sphericity was overall associated with global and apical radial ( p = 0.001, R 2 = 0.09; p < 0.0001, R 2 = 0.17) and circumferential strain ( p = 0.001, R 2 = 0.10; p = 0.04, R 2 = 0.04), irrespective of the presence of aortic stenosis and/or regurgitation and controlling for age and hypertension status. LV strain was not associated with arch architecture. Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.