Clinical experience regarding safety and diagnostic value of cardiovascular magnetic resonance in patients with a subcutaneous implanted cardioverter/defibrillator (S-ICD) at 1.5 T.
1.5 t皮下植入心律转复器/除颤器 (s-icd) 患者心血管磁共振安全性和诊断价值的临床经验。
- 作者列表："Holtstiege V","Meier C","Bietenbeck M","Chatzantonis G","Florian A","Köbe J","Reinke F","Eckardt L","Yilmaz A
BACKGROUND:Cardiovascular magnetic resonance (CMR) studies in patients with implanted cardioverter/defibrillators (ICD) are increasingly required in daily clinical practice. However, the clinical experience regarding the feasibility as well as clinical value of CMR studies in patients with subcutaneous ICD (S-ICD) is still limited. Besides safety issues, image quality and analysis can be impaired primarily due the presence of image artefacts associated with the generator. METHODS:Twenty-three patients with an implanted S-ICD (EMBLEM, Boston Scientific, Marlborough, Massachusetts, USA; MR-conditional) with suspected cardiomyopathy and/or myocarditis underwent multi-parametric CMR imaging. Studies were performed on a 1.5 T CMR scanner after device interrogation and comprised standard a) balanced steady state free precession cine, b) T2 weighted-edema, c) velocity-encoded cine flow, d) myocardial perfusion, e) late-gadolinium-enhancement (LGE)-imaging and f) 3D-CMR angiography of the aorta. In case of substantial artefacts, alternative CMR techniques such as spoiled gradient-echo cine-sequences and wide-band inversion-recovery LGE (wb-LGE) sequences were applied. RESULTS:Successful CMR studies could be performed in all patients without any case of unexpected early termination or relevant technical complication other than permanent loss of the S-ICD system beeper volume in 52% of our patients. Assessment of cine-CMR images was predominantly impaired in the left ventricular (LV) anterior, lateral and inferior wall segments and a switch to spoiled gradient echo-based cine-CMR allowed an accurate assessment of cine-images in N = 17 (74%) patients with only limited artefacts. Hyperintensity artefacts in conventional LGE-images were predominantly observed in the LV anterior, lateral and inferior wall segments and image optimisation by use of the wb-LGE was helpful in 15 (65%) cases. Aortic flow measurements and 3D-CMR angiography were assessable in all patients Perfusion imaging artefacts precluded a meaningful assessment in at least one half of the patients. A benefit in clinical-decision making was documented in 17 (74%) patients in the present study. CONCLUSION:Safe 1.5 T CMR imaging was possible in all patients with an S-ICD, though the majority had permanent loss of the S-ICD beeper volume. Achieving good image quality may be challenging in some patients - particularly for perfusion imaging. Using spoiled gradient echo-based cine-sequences and wb-LGE sequences may help to reduce the extent of artefacts, thereby allowing accurate cardiac assessment. Thus, 1.5 T CMR studies should not be withhold in patients with S-ICD for safety concerns and/or fear of extensive imaging artefacts precluding successful image analysis.
背景: 在植入心律转复器/除颤器 (ICD) 的患者中进行心血管磁共振 (CMR) 研究在日常临床实践中越来越需要。然而，关于CMR研究在皮下ICD (s-icd) 患者中的可行性以及临床价值的临床经验仍然有限。除了安全问题之外，图像质量和分析可能主要由于与发生器相关联的图像伪影的存在而受到损害。 方法: 23例疑似心肌病和/或心肌炎的植入s-icd患者 (美国马萨诸塞州马尔伯勒波士顿科学公司会徽; 有条件的MR) 接受了多参数CMR成像。设备询问后，在1.5 T CMR扫描仪上进行研究，包括标准a) 平衡稳态自由进动电影，b) T2加权水肿，c) 速度编码电影流，d) 心肌灌注，e) 延迟钆增强 (LGE)-成像和f) 主动脉的3D-CMR血管造影。在大量人工制品的情况下，应用了替代CMR技术，如破坏的梯度回波电影序列和宽带反转恢复LGE (wb-LGE) 序列。 结果: 所有患者均可以成功进行CMR研究，除了52% 的患者永久性丧失s-icd系统蜂鸣器体积外，无任何意外提前终止或相关技术并发症。cine-CMR图像的评估主要在左心室 (LV) 前壁段、侧壁段和下壁段受损，转换为基于受损梯度回波的cine-CMR允许在只有有限伪影的n = 17 (74%) 患者中准确评估电影图像。在常规LGE图像中，主要在LV前壁段、侧壁段和下壁段中观察到高强度伪影，在15例 (65%) 病例中，使用wb-lge进行图像优化是有帮助的。可在所有患者中评估主动脉血流测量和3D-CMR血管造影，在至少一半的患者中，灌注成像伪影阻止有意义的评估。在本研究中，17例 (74%) 患者在临床决策中获益。 结论: 安全的1.5 t CMR成像在所有s-icd患者中都是可能的，尽管大多数患者的s-icd蜂鸣器体积永久性丢失。在一些患者中实现良好的图像质量可能是具有挑战性的-特别是对于灌注成像。使用被破坏的基于梯度回波的电影序列和wb-lge序列可以有助于减少伪影的程度，从而允许准确的心脏评估。因此，出于安全考虑和/或担心广泛的成像伪影妨碍成功的图像分析，不应在s-icd患者中保留1.5 t CMR研究。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.