Cardiovascular magnetic resonance (CMR) is an established, non-invasive technique to comprehensively assess cardiovascular structure and function in a variety of acquired and inherited cardiac conditions. In the process of acquiring CMR images, the inferior neck, entire thorax, and upper abdomen are routinely imaged, particularly in the initial multi-slice axial and coronal images. Identifying and reporting extra-cardiac findings at the time of CMR has ethical, financial, and medicolegal implications. Not all extra-cardiac findings are incidental, and occasionally they may contribute to the interpretation of the primary cardiac pathology, as some cardiac conditions have multi-systemic extra-cardiac involvement. However, the majority of extra-cardiac findings are incidental but may still be clinically important and may alter clinical management. Given that several of the cardiovascular risk factors for atherosclerosis are also risk factors for malignancy, certain patient groups undergoing CMR are at potential risk for important extra-cardiac findings. This chapter aims to provide a systematic overview of the type of extra-cardiac findings that may be detected on CMR, subdivided by anatomical location. Focus is placed on normal variant anatomy that may be confused for pathology, common extra-cardiac findings, and important imaging signs that help distinguish important pathology from benign entities. A framework to the approach and potential further diagnostic workup of incidental extra-cardiac findings discovered at the time of CMR is provided.
Background: COVIDTrach is a UK multi-centre prospective cohort study project evaluating the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation. It also examines the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure. Method: An invitation to participate was sent to all UK NHS departments involved in tracheostomy in mechanically ventilated patients with COVID-19. Data was entered prospectively and clinical outcomes updated over time via an online database (REDCap). Clinical variables were compared with clinical outcomes using multivariable regression analysis, with logistic regression used to develop a prediction model for mortality. Participants recorded whether any of the operators tested positive for SARS-CoV-2 within two weeks of the procedure. Findings: The cohort comprised 1605 tracheostomy cases from 126 UK hospitals. The median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration requirement on the day of tracheostomy, PEEP setting, pyrexia, number of days of ventilation before tracheostomy, C-reactive protein and the use of anticoagulation and inotropic support independently predicticted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within two weeks following the procedure. Interpretation: Tracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical indicators that are predictive of mortality. Optimal timing of the procedure remains to be determined. Funding: The COVIDTrach project is supported by the Wellcome Trust UCL COVID-19 Rapid Response Award and the National Institute for Health Research.
Background: The left ventricular ejection fraction does not accurately predict exercise capacity or symptom severity and has a limited role in predicting prognosis in heart failure. A better method of assessing ventricular performance is needed to aid understanding of the pathophysiological mechanisms and guide management in conditions such as heart failure. In this study, we propose two novel measures to quantify myocardial performance, the global longitudinal active strain energy (GLASE) and its density (GLASED) and compare them to existing measures in normal and diseased left ventricles. GLASED calculates the work done per unit volume of muscle (energy density) by combining information from myocardial strain and wall stress (contractile force per unit cross sectional area). Methods: Magnetic resonance images were obtained from 183 individuals forming four cohorts (normal, hypertension, dilated cardiomyopathy, and cardiac amyloidosis). GLASE and GLASED were compared with the standard ejection fraction, the corrected ejection fraction, myocardial strains, stroke work and myocardial forces. Results: Myocardial shortening was decreased in all disease cohorts. Longitudinal stress was normal in hypertension, increased in dilated cardiomyopathy and severely decreased in amyloid heart disease. GLASE was increased in hypertension. GLASED was mildly reduced in hypertension (1.39 ± 0.65 KJ/m3), moderately reduced in dilated cardiomyopathy (0.86 ± 0.45 KJ/m3) and severely reduced in amyloid heart disease (0.42 ± 0.28 KJ/m3) compared to the control cohort (1.94 ± 0.49 KJ/m3). Conclusion: GLASED progressively decreased in the hypertension, dilated cardiomyopathy and cardiac amyloid cohorts indicating that mechanical work done and systolic performance is severely reduced in cardiac amyloid despite the relatively preserved ejection fraction. GLASED provides a new technique for assessing left ventricular myocardial health and contractile function. Graphical abstract The figure shows a graphical summary of the study with the derivation, meaning and primary results of the novel measurements GLASED and GLASE. The left-hand panel shows the calculations for peak stress and strain with the middle-panel showing the calculations for active strain energy and strain energy density. The right-hand panel shows the changes in global longitudinal active strain energy density (GLASED) and global longitudinal active strain energy (GLASE) of the left ventricle in the various cohorts. Clinical perspective Current measures of left ventricular performance such as ejection fraction and myocardial strain have important shortcomings. These limitations are attributable to the confounding effects of abnormal geometric changes and the loading conditions. This study introduces a novel measure of left ventricular systolic function called the global longitudinal active strain energy density (GLASED). GLASED combines information from left ventricular structural pattern (wall thickness and internal cavity size), systolic pressure and myocardial strain and calculates the work done (mechanical energy produced) per unit volume of myocardium during systole. GLASED should prove to be more accurate than the ejection fraction and myocardial strain in assessing left ventricular myocardial function.
We describe the case of a 21-year-old female with Cutis Laxa presenting with an acute coronary syndrome. A CT coronary angiogram (CTCA) diagnosed spontaneous coronary artery dissection (SCAD) of the right coronary artery, which was successfully managed with medical therapy. Cutis Laxa is a rare connective-tissue disorder in which the skin becomes inelastic. Lax, redundant skin hangs in folds give a prematurely aged appearance and several forms of the disease have been described,. Although certain cardiovascular complications are recognised in Cutis Laxa, to our knowledge SCAD has not been previously described. SCAD is an uncommon cause of acute coronary syndrome (ACS) and sudden cardiac death. The condition particularly affects young females, those with connective tissue diseases, arteriopathies, pregnant females, contraceptive use and cocaine use. Atherosclerotic risk factors are seldom reported. The condition is under diagnosed as symptoms may not generate a high index of clinical suspicion in this demographic. Diagnosis is traditionally made on invasive coronary angiogram although the procedure carries risks in SCAD and non-invasive CTCA should be considered in appropriately selected patient cohorts or as an adjunctive measure to assess for extra coronary vascular abnormalities. Our patient was diagnosed on CTCA, avoiding the need for invasive catheter angiogram.
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