Cardiac resynchronization therapy is a high cost therapeutic option with proven efficacy on improving symptoms of ventricular failure and for reducing both hospitalization and mortality. However, a significant number of patients do not respond to cardiac resynchronization therapy that is due to various reasons. Identification of the optimal pacing site is crucial to obtain the best therapeutic result that necessitates careful patient selection. Currently, using echocardiography for mechanical dyssynchrony assessment performs patient selection. Multi-Detector-Row Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI) are new imaging techniques that may assist the cardiologist in patient selection. These new imaging techniques have the potential to improve the success rate of cardiac resynchronization therapy, due to pre-interventional evaluation of the venous coronary anatomy, to evaluation of the presence of scar tissue, and to improved evaluation of mechanical dyssynchrony. In conclusion, clinical issues associated with heart failure in potential candidates for cardiac resynchronization therapy, and the information regarding this therapy that can be provided by the imaging techniques echocardiography, MDCT, and MRI, are reviewed.
A 19-year-old man with the diagnosis of acute pericarditis based on the classic clinical syndrome and an ECG ( Figure 1A) was referred to our cardiac magnetic resonance (CMR) unit 1 month after his hospital admission because of suspected associated acute myocarditis. A follow-up ECG within the time frame of referral showed essentially significant regression of ST elevation ( Figure 1B). An echocardiogram performed at the referring hospital on the same day ( Figure 2A and 2B) was reported as showing mild concentric left ventricular (LV) hypertrophy with good LV systolic function (ejection fraction 75%).The combination of 3 CMR sequences (cine imaging with the new balanced steady-state free-precession technique ͓shown in Figure 3, first row͔; contrast-enhancement inversion recovery CMR imaging in the late phase after gadolinium injection [shown in Figure 3, second row], and short -inversion recovery T2-weighted imaging [ Figure 3, third row]) confirmed the diagnosis of acute pericarditis (columns 1 and 3, Figure 3). With the same approach, associated acute myocarditis or myocardial fibrosis was excluded. The pericardium was of normal thickness, with no evidence of constrictive physiology or significant effusion. There was mild LV dilatation, borderline increased LV mass, and no regional wall-motion abnormality, with an LV ejection fraction of 73%. The patient was treated with nonsteroidal antiinflammatory medication for persistent symptoms over a 6-week period and remained asymptomatic thereafter. Echocardiography performed 2 months after initial presentation ( Figure 2C and 2D) showed no significant change compared with the echocardiogram performed at the time of the initial CMR scan. A follow-up CMR scan after 6 months (columns 2 and 4, Figure 3) showed normal LV size, borderline increased LV mass, and resolution of pericardial inflammatory process.Short -inversion recovery T2-weighted imaging demonstrated hyperintense signal from the pericardium (arrowed in both images labeled E in Figure 3) in the initial scan. This imaging technique is particularly sensitive for tissue edema, a substantial feature of an acute inflammatory reaction, because an increase of free-water content due to lymphocyte infiltration causes T2 relaxation time prolongation. The contrastenhancement inversion recovery MRI sequences also demonstrated hyperenhancement of the pericardium (arrowed visceral and parietal pericardium in both images labeled C in Figure 3), which can be due to severe edema that leads to an increased distribution volume of gadolinium contrast and/or cellular necrosis. The reversibility of the hyperenhancement is consistent with no significant necrosis and healing of the inflammatory process in this case.There was significant improvement of the clinical picture and of the ECG changes at the time of the initial CMR scan. Interestingly, although the echocardiogram showed no specific abnormality, the ECG still showed approximately 1 mm of ST elevation, and the combined approach of the 3 described CMR techniques proved to b...
Congenital anomalies of the external genitalia occur in 2-3 per 100 infants. These anomalies might bring variable degrees of morbidity to the infant and often constitute diagnostic challenges for health professionals. We present a case report of a fetus with bilateral vulvar cysts diagnosed during the third trimester ultrasound. The cysts spontaneously regressed before birth and the newborn showed no genital anomalies at birth.
A 48-year-old man presented with progressive exertional dyspnea, lethargy, and intermittent fever. He had undergone resection of subvalvular aortic stenosis at 12 years of age and subsequent resection of residual subaortic stenosis at 24 years of age when an apical vent had been placed in the left ventricle (LV) and closed with a pledgeted suture. The patient had recovered well after both operations and led an active life. Catheter coronary angiography and ventriculography 4 years before his current presentation showed no significant coronary arterial or LV pathology, except for a pullback gradient of 19 mm HG across the LV outflow tract. Echocardiography subsequently showed progression of mild to moderate subaortic stenosis, mild aortic valve stenosis, and moderate regurgitation.On clinical examination, there was visible pulsation of the left chest and a large pulsatile mass palpable subcostally. The patient was anemic (hemoglobin, 7.5 g/dL). Methicillin-sensitive Staphylococcus aureus was cultured from blood samples, and antibiotics were given accordingly. A chest x-ray showed a large opacity apparently continuous with the apical region of the LV (Figure 1). An ECG showed T-wave inversion in leads V 3 through V 6 (Figure 2). A transthoracic echocardiogram showed a large multiloculated, heteroechogenic structure inferior to the apex with smooth-walled hypoechogenic areas showing spontaneous echo contrast ( Figure 3A and Movie I). Color Doppler flow mapping showed flow in the hypoechogenic areas, with evidence of communication with the LV apex ( Figure 3B and Movie II). The aortic valve appeared thickened and, by then, severely regurgitant. Cardiovascular magnetic resonance (CMR) showed a large, rounded mass ( Figure 4A and 4B) measuring 11ϫ8ϫ9 cm. Cine imaging showed evidence of jet flow into and out of the loculated cavities of a false aneurysm in the upper half of the mass ( Figure 4C and 4D). Below these, the mass showed intermediate signal intensity with a region of brighter signal on T2-weighted turbo spin-echo imaging ( Figure 4B) suggestive of abscess formation. The mass extended down to and displaced the left hemidiaphragm. The anterior and lateral borders extended to the chest wall. The CMR study also showed a trileaflet aortic valve with mild subaortic stenosis and central aortic regurgitation, with a regurgitant fraction of 40% by phase-contrast velocity mapping.The patient agreed to undergo cardiac surgery. Because of possibility of perforating the false aneurysm, the approach was first to expose the aorta and right atrium and establish bypass through a limited reopening of the previous median sternotomy. Closer inspection of the aortic valve showed a thickened and deformed right coronary cusp with suspected vegetation. The apex of the LV was then exposed and detached from the false aneurysm. Beyond it, a large abscess cavity was found, extending through the pericardial cavity into the pleural cavity above the diaphragm. The pus drained contained 2 large Teflon pledgets. The aortic valve was then r...
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