Coronary Risk Assessment and Management Options in Chronic Kidney Disease Patients Prior to Kidney Transplantation

Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients. Nearly half the deaths in transplanted patients are attributed to cardiac causes and almost 5% of these deaths occur within the first year after transplantation. The ideal strategies to screen for coronary artery disease (CAD) in chronic kidney disease patients who are evaluated for kidney transplantation (KT) remain controversial. The American Society of Transplantation recommends that patients with diabetes, prior history of ischemic heart disease or an abnormal ECG, or age ≥50 years should be considered as high-risk for CAD and referred for a cardiac stress test and only those with a positive stress test, for coronary angiography. Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population. This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients

Integral role of cardiovascular magnetic resonance imaging in the diagnostic workup of suspected takotsubo cardiomyopathy: Avoiding misdiagnosis

Takotsubo cardiomyopathy (TC), or stress cardiomyopathy, is an increasingly recognized acute but reversible myopathic process affecting the ventricle. Although specific criteria have been published to diagnose this entity, traditionally, coronary angiography has been used to exclude coronary artery disease in this condition. We present a case initially suspected to be TC based on clinical and angiographic data. However, cardiovascular magnetic resonance with delayed enhancement imaging with gadolinium identified occult coronary artery disease and refuted the original diagnosis of TC. Cardiovascular magnetic resonance should be an integral part of the diagnostic workup of suspected Takotsubo cardiomyopathy. (Cardiol J 2007; 14: 592-594)

Advances in Cardiac Computed Tomography

Coronary cardiac computed tomography (CCTA) has seen rapid improvements in technology including hardware and postprocessing techniques that have contributed to its rapid growth and enabled it to remain in the forefront on diagnostic imaging. Important technological advances include wider detectors for greater coverage with less gantry rotation times, dual-source computed tomography (CT) with improved temporal resolution, dual-energy CT where simultaneous imaging at different energies to increase the contrast difference between different tissues enhances diagnostic accuracy, and emergence of spectral CT to enhance atherosclerotic imaging through nanoparticle technology. Software advances include iterative reconstruction methodologies to reduce noise and radiation doses, plaque imaging and quantification tools to assess plaque morphology and stenosis severity. Processing advances using computational fluid dynamics now enables the determination of fractional flow reserve (FFR). Another important advancement in CCTA physiologic imaging is CCTA perfusion imaging to detect ischemia and compares favorably with myocardial perfusion imaging and coronary angiographic stenosis. Finally, large registry studies and single-center studies have now been published assessing the incremental value of coronary calcium score, CT plaque severity of disease and have demonstrated that the CCTA carries strong prognostic value over and above traditional risk assessment in predicting adverse outcomes

Imaging of persistent left sided superior vena cava with echocardiography and multi-slice computed tomography: Implications for daily practice

Persistent left sided superior vena cava is a congenital abnormality encountered not uncommonly by the echocardiographer or cardiac radiologist. Recognition of its presence is important in the differential diagnosis of dilatation of the coronary sinus. We discuss the echocardiographic and computed tomography findings of this congenital abnormality, and the implications for clincal practice. (Cardiol J 2011; 18, 3: 332–336

Regadenoson — Overview of Applications in Cardiology

Coronary artery disease is a leading cause of morbidity and mortality in developed countries. According to a Center for Disease Control report, one out of four deaths is attributed to coronary artery disease. It costs the United States human lives, productivity, and more than 100 billion dollars each year. Due to increased incidence in both men and women and all ethnicities, risk stratification of patients at risk for developing myocardial infarction and death is of paramount importance. Various tests are available for diagnosis and prognosis in coronary heart disease such as exercise treadmill testing, coronary calcium scoring, dobutamine stress echocardiography, exercise, dipyridamole, adenosine or dobutamine stress nuclear myocardial perfusion imaging (MPI), and dobutamine or adenosine stress cardiac magnetic resonance imaging. Since 2008 a new vasodilator, regadenoson (REG), has become available and is now widely used for nuclear perfusion imaging. Pharmacologic stress testing challenges the coronary flow reserve to evaluate the hyperemic capacity of the heart, which can be impaired in significant epicardial stenosis or microvascular dysfunction. In the presence of either of these conditions, ischemia induced by hyperemia manifests as wall motion abnormalities on echocardiography or as perfusion defects in nuclear perfusion imaging

Integralna rola metod obrazowania układu sercowo-naczyniowego opartych na rezonansie magnetycznym w diagnostyce klinicznego podejrzenia kardiomiopatii takotsubo: unikanie błędnych rozpoznań

Kardiomiopatia takotsubo, określana również mianem kardiomiopatii stresowej, jest coraz częściej rozpoznawanym, ostrym, ale odwracalnym miopatycznym procesem uszkadzającym komorę mięśnia sercowego. Mimo że opublikowano specyficzne kryteria diagnostyczne dla tej jednostki chorobowej, tradycyjnie wciąż wykonuje się badanie koronarograficzne naczyń wieńcowych w celu wykluczenia choroby wieńcowej. W niniejszej pracy zaprezentowano przypadek pacjenta ze wstępnym podejrzeniem kardiomiopatii takotsubo. Powyższą diagnozę postawiono na podstawie danych klinicznych i angiograficznych. Jednak po wykonaniu badań obrazowych układu sercowo-naczyniowego za pomocą rezonansu magnetycznego z opóźnionym wzmocnieniem gadolinem wykryto ukrytą we wcześniejszych badaniach chorobę wieńcową i wykluczono postawioną początkowo diagnozę kardiomiopatii takotsubo. Obrazowanie układu sercowo-naczyniowego metodą rezonansu magnetycznego powinno stanowić integralną część procesu diagnostycznego w przypadku podejrzenia kardiomiopatii takotsubo. (Folia Cardiologica Excerpta 2008; 3: 93-96

Congenital Supravalvular Pulmonic Stenosis, Maybe or Maybe Not

Introduction: It is extremely rare for leiomyosarcomas to affect the cardiovascular system. High degree of suspicion is required to diagnose this tumor in patients presenting with symptoms suggestive of a cardiac etiology. Because of the high mortality associated with this malignancy, early and aggressive intervention is crucial. Furthermore, imaging modalities may not adequately identify this tumor, as will be presented in this case leading challenges in diagnosis. Case: We present a case of a 59 year old female with a history of hypothyroidism who presented with progressive exertional dyspnea and palpitations. She underwent a chest CT which excluded pulmonary embolism but revealed diffuse long tubular narrowing above pulmonary valve involving main pulmonary artery raising suspicion forsupravalvularpulmonic stenosis. A 2D echocardiogram revealed normal left and right ventricular function, elevated systolic velocities distal to the pulmonic valve suggestive of supra-valvularpulmonary artery stenosis. A cardiac MRI was performed conforming pulmonary artery narrowing of the main pulmonary artery 1 cm above the pulmonic valve, with the narrowest area measuring 9mm in diameter. The pulmonic valve appeared uninvolved. She underwent a cardiac catheterization which demonstrated a peak gradient of 67 mm Hg across the stenotic lesion in the main PA. She was then diagnosed as symptomatic congenital isolated supra-valvularpulmonic stenosis. She was referred for cardiac surgery for relief of supra-valvularstenosis and reconstruction of the main pulmonary artery. Intraoperatively, a segment of the pulmonary artery was circumferentially narrowed by an infiltrative process. Frozen section analysis confirmed sarcoma, possible spindle cell variant. The main pulmonary artery was resected to the level of the pulmonary artery bifurcation, and a 23 mm aortic homograft was sewed in place. Subsequent biopsy revealed high grade spindle cell sarcoma, with morphologic features suggestingleiomyosarcoma. Re-review of the CT and MRI failed to conclusively predict the presence of this encircling tumor around pulmonary artery. Following surgery and recovery, she underwent a PET scan which demonstrated a small lytic lesion at L1, with possible metastatic femoral neck lesion. She was seen by hematology/oncology with recommendations to undergo localized radiotherapy and chemotherapy. Patient delayed treatment for her sarcoma in anticipation of a second opinion, and she ultimately passed away. Discussion: Leiomyosarcoma involving the pulmonary artery is extremely rare and usually manifests as a filling defect involving the pulmonary artery, mimicking a pulmonary embolism. In this case, multiple imaging studies were performed including a CT, MR and TTE, all of which failed torevealedthe extrinsic circumferential compression of the main pulmonary artery. In patients that do not have a congenital cardiac history (iepulmonic stenosis), a high degree of suspicion is required to rule out extrinsic compression by a tumor, as was evident in our case.https://scholarlycommons.henryford.com/merf2019caserpt/1008/thumbnail.jp

Clinical and echocardiographic features of aorto-atrial fistulas

Aorto-atrial fistulas (AAF) are rare but important pathophysiologic conditions of the aorta and have varied presentations such as acute pulmonary edema, chronic heart failure and incidental detection of the fistula. A variety of mechanisms such as aortic dissection, endocarditis with pseudoaneurysm formation, post surgical scenarios or trauma may precipitate the fistula formation. With increasing survival of patients, particularly following complex aortic reconstructive surgeries and redo valve surgeries, recognition of this complication, its clinical features and echocardiographic diagnosis is important. Since physical exam in this condition may be misleading, echocardiography serves as the cornerstone for diagnosis. The case below illustrates aorto-left atrial fistula formation following redo aortic valve surgery with slowly progressive symptoms of heart failure. A brief review of the existing literature of this entity is presented including emphasis on echocardiographic diagnosis and treatment

Prognostyczne znaczenie ujemnego wyniku echokardiograficznej próby dobutaminowej w warunkach submaksymalnego obciążenia - badanie z 3-letnią obserwacją

Wstęp: Celem badania była ocena wartości predykcyjnej ujemnego wyniku echokardiograficznej próby dobutaminowej w warunkach submaksymalnego obciążenia (NsubDSE) w odniesieniu do występowania poważnych incydentów sercowych. Metody i wyniki: Analizie poddano pacjentów z ujemnym wynikiem echokardiograficznej próby dobutaminowej należących do dwóch grup wyróżnionych w zależności od przewidywanej maksymalnej częstości rytmu serca (PMHR) (< 85% oraz &#8805; 85% PMHR), w których oceniano występowanie poważnych niepożądanych incydentów sercowych w ciągu 3 lat. Spośród 756 pacjentów z ujemnym wynikiem echokardiograficznej próby dobutaminowej u 415 chorych wartość PMHR wyniosła 85% lub więcej. W obu grupach stwierdzono podobny odsetek osób z frakcją wyrzutową powyżej 50% (80,6% vs. 81,9%; p = 0,66). Grupa z NsubDSE charakteryzowała się większą częstością stosowania leków hamujących przewodzenie przez łącze przedsionkowo-komorowe (58,7% vs. 39,9%; p < 0,0001) oraz większą częstością występowania cukrzycy (38,7% vs. 27,6%; p = 0,001). Analiza Kaplana-Meiera nie wykazała różnic przeżycia bez zgonu sercowego (98% vs. 98%; p = 0,88), zawału serca niezakończonego zgonem (94% vs. 94%; p = 0,85) lub wszystkich poważnych incydentów sercowych (81% vs. 78%; p = 0,24). Czynnikami predykcyjnymi incydentów sercowych w analizie wielozmiennej były cukrzyca i zachowana frakcja wyrzutowa (p = 0,005). Wnioski: W niniejszym badaniu osiągnięcie NsubDSE wiązało się z korzystnym rokowaniem. Uzyskiwano je częściej u chorych na cukrzycę, ale w tej grupie częściej występowały też incydenty sercowe pomimo zachowanej frakcji wyrzutowej. U osób z tej grupy dużego ryzyka wskazana jest więc dalsza diagnostyka choroby wieńcowej

Coronary computed tomography angiography in dialysis patients undergoing pre-renal transplantation cardiac risk stratification

Background: This study addresses the safety, feasibility, and interpretability of coronary computed tomography angiography (CCTA) in excluding significant coronary artery disease in end-stage renal disease patients on dialysis undergoing pre-renal transplant cardiac risk evaluation. Methods: Twenty nine patients (55.5 &#177; 10.2 years) undergoing cardiac risk assessment prior to renal transplantation, underwent research CCTA with calcium scoring and formed the study group. All CCTAs were performed using retrospective acquisition, with beta-blockade provided one hour prior to scanning. Results: No major complications occurred in this group up to 30 days after CCTA. Of the total of 374 segments interpreted by both readers, only 36 (10%) were uninterpretable by both readers. Of these, 31 (86%) were from distal segments or branches. On a segmental level, there was 95% concordance between both readers for < 50% stenosis detection. Only three out of 28 (11%) CCTAs were deemed uninterpretable. Ten patients (36%) had zero calcium score, despite being on dialysis with no evidence of obstructive coronary artery disease by CCTA. Conclusions: CCTA is feasible and safe in end-stage renal disease dialysis patients with the advent of 64-slice CCTA. Despite significant calcium burden, there was excellent inter-observer agreement at segment level for the left main and all three proximal-mid coronary arteries in excluding obstructive coronary artery disease (> 50% stenosis). (Cardiol J 2010; 17, 4: 349-361