Faculty Bibliography

BACKGROUND:Cardiac lipomas are usually benign but can cause significant hemodynamic and arrhythmic complications, such as ventricular tachycardia, depending on size, location, and myocardial involvement. CASE 1 SUMMARY: An 18-year-old man presented with cardiac arrest during exercise. Following a normal coronary angiogram, a defibrillator was implanted. After recurrent shocks, imaging demonstrated a large cardiac lipoma. Surgical excision resulted in cessation of his recurrent ventricular tachycardia. CASE 2 SUMMARY: A 25-year-old woman presented with ventricular tachycardia, and imaging revealed a large cardiac lipoma with coronary artery encasement. Surgical resection led to resolution of ventricular arrhythmias, and permanent defibrillator implantation was avoided. DISCUSSION/CONCLUSIONS:These cases highlight how cardiac lipomas can lead to ventricular arrhythmias through mass effect and proximity to the coronary vasculature. Multimodal imaging was indispensable for the diagnosis and surgical planning for these cases. TAKE-HOME MESSAGES/CONCLUSIONS:Cardiac lipomas can cause life-threatening ventricular arrhythmias. A multimodal imaging approach combined with multidisciplinary team evaluation is essential for accurate diagnosis and management.

BACKGROUND:Coronary artery anomalies, increasingly recognized as a cause of angina because of higher use of noninvasive imaging, can lead to debilitating symptoms and increased risk of sudden death. CASE SUMMARY/METHODS:A 49-year-old woman presented with years of daily exertional chest pain/dyspnea. Coronary computed tomography angiography revealed a left main coronary artery with a pinhole-like ostium, an inferior takeoff between the noncoronary and left coronary cusps, and poststenotic dilatation. The patient declined surgery and underwent successful intravascular ultrasound-guided percutaneous coronary intervention (PCI) with symptom resolution. DISCUSSION/CONCLUSIONS:This is a successful case report of PCI to correct a pinhole-like ostium of the left main coronary artery. Given the patient's progressive symptoms, the benefit of preventing a life-threatening arrhythmia and improving her function outweighed the procedural risks. TAKE-HOME MESSAGES/CONCLUSIONS:This case demonstrates that PCI is a safe and feasible approach to treat critical pinhole-like left main stenosis in select patients, to prevent life-threatening ischemia-induced arrhythmias and improve functional capacity. Careful longitudinal surveillance will be essential to monitor continued stent patency and freedom from symptoms.

Accelerated 30 min cardiac magnetic resonance (CMR) examinations combining cutting-edge acquisition, reconstruction, and workflow methods have the potential to expand democratization to CMR, increase throughput, enhance patient experience, and maintain diagnostic quality. At the same time, the integration of artificial intelligence into CMR workflow offers additional opportunities to improve planning, acquisition, reconstruction, and post-processing, further enhancing efficiency without compromising quality. Here, we review the rationale, design, implementation, and impact of a streamlined 30 min CMR protocol developed at our institution for ventricular ablation and hypertrophic cardiomyopathy indications.

BACKGROUND:Differentiating healed spontaneous coronary artery dissection (SCAD) from woven coronary arteries or recanalized thrombus can be challenging. CASE SUMMARY/METHODS:A 33-year-old man presented with chest pain and was found to have a severe atypical-appearing lesion in the proximal left anterior descending artery. Differential diagnoses included healed dissection, woven coronary, and recanalized thrombus. Coronary computed tomography angiography demonstrated SCAD. Optical coherence tomography revealed extensive lipid plaque, foamy macrophages, cholesterol crystals, and plaque rupture with recanalized thrombus. The patient underwent successful percutaneous coronary intervention, with complete resolution of symptoms. DISCUSSION/CONCLUSIONS:Angiographic and computed tomographic features of healed SCAD, woven coronary arteries, and recanalized thrombus can overlap. Optical coherence tomography can differentiate by visualizing dissection flaps, intramural hematomas (SCAD), or small channels within a thrombus. TAKE-HOME MESSAGES/CONCLUSIONS:Healed SCAD, woven coronary artery, and recanalized thrombus have resembling angiographic features. Differentiating among them is critical, as the management differs. Intravascular imaging can help.

MR imaging is increasingly used in evaluation of patients with known or suspected hypertrophic cardiomyopathy (HCM), as it provides useful information on cardiac structure, function, and tissue characterization that is complementary to echocardiography. While the adverse effect of left ventricle (LV) outflow tract obstruction on blood flow patterns is well characterized by the midsystolic drop in LV ejection velocities and flow, flow patterns in HCM with mid-LV obstruction, with or without apical aneurysm, are less well characterized. MR imaging can provide additional information on alterations of blood flow patterns in these HCM phenotypes and "paradoxic" flows associated with apical aneurysms.

Preprocedural chest or cardiac imaging for cardiothoracic surgery is focused on the imaging necessary to inform the performance of a surgical procedure after an initial diagnosis and the decision to operate has been made with consideration of patient comorbidities and anesthesia risk. The diverse range of noncoronary cardiac surgeries, coronary cardiac surgeries, and thoracic surgeries each have their own unique surgical techniques, risks, and complications, which can further vary between patients undergoing first time or repeat cardiothoracic surgery. This document reviews the literature for preprocedural chest or cardiac imaging in patients with and without a history of cardiothoracic surgery. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Cardiomyopathies represent a diverse group of heart diseases that can be broadly classified into ischemic and nonischemic etiologies, each requiring distinct diagnostic approaches. Noninvasive imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), play a pivotal role in the diagnosis, risk stratification, and prognosis of these conditions. This paper reviews the characteristic CT and MRI findings associated with ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM), focusing on their ability to provide detailed anatomical, functional, and tissue characterization. In ICM, CT and MRI reveal myocardial scarring, infarct size, and coronary artery disease, while MRI further distinguishes tissue viability through late gadolinium enhancement (LGE). Conversely, nonischemic cardiomyopathies demonstrate a wide array of findings, with MRI's LGE pattern analysis being particularly critical for identifying specific subtypes, such as restrictive, hypertrophic, or dilated cardiomyopathies. By comparing the strengths and limitations of these modalities, this paper highlights their complementary roles in improving diagnostic accuracy, risk stratification, prognosis, and therapeutic decision making in both ischemic and nonischemic cardiomyopathies.

Contrast enhanced pulmonary vein magnetic resonance angiography (PV CE-MRA) has value in atrial ablation pre-procedural planning. We aimed to provide high fidelity, ECG gated PV CE-MRA accelerated by variable density Cartesian sampling (VD-CASPR) with image navigator (iNAV) respiratory motion correction acquired in under 4 min. We describe its use in part during the global iodinated contrast shortage. VD-CASPR/iNAV framework was applied to ECG-gated inversion and saturation recovery gradient recalled echo PV CE-MRA in 65 patients (66 exams) using .15 mmol/kg Gadobutrol. Image quality was assessed by three physicians, and anatomical segmentation quality by two technologists. Left atrial SNR and left atrial/myocardial CNR were measured. 12 patients had CTA within 6 months of MRA. Two readers assessed PV ostial measurements versus CTA for intermodality/interobserver agreement. Inter-rater/intermodality reliability, reproducibility of ostial measurements, SNR/CNR, image, and anatomical segmentation quality was compared. The mean acquisition time was 3.58 ± 0.60 min. Of 35 PV pre-ablation datasets (34 patients), mean anatomical segmentation quality score was 3.66 ± 0.54 and 3.63 ± 0.55 as rated by technologists 1 and 2, respectively (p = 0.7113). Good/excellent anatomical segmentation quality (grade 3/4) was seen in 97% of exams. Each rated one exam as moderate quality (grade 2). 95% received a majority image quality score of good/excellent by three physicians. Ostial PV measurements correlated moderate to excellently with CTA (ICCs range 0.52-0.86). No difference in SNR was observed between IR and SR. High quality PV CE-MRA is possible in under 4 min using iNAV bolus timing/motion correction and VD-CASPR.

Clinical application of cardiac magnetic resonance (CMR) is expanding but CMR assessment of LV diastolic function is still being validated. The purpose of this study was to validate assessments of left ventricular (LV) diastolic dysfunction (DD) using CMR by comparing with transthoracic echocardiography (TTE) performed on the same day. Patients with suspected or diagnosed cardiomyopathy (n = 63) and healthy volunteers (n = 24) were prospectively recruited and included in the study. CMR diastolic parameters were measured on cine images and velocity-encoded phase contrast cine images and compared with corresponding parameters measured on TTE. A contextual correlation feature tracking method was developed to calculate the mitral annular velocity curve. LV DD was classified by CMR and TTE following 2016 guidelines. Overall DD classification was 78.1% concordant between CMR and TTE (p < 0.0001). The trans-mitral inflow parameters correlated well between the two modalities (E, r = 0.78; A, r = 0.90; E/A, r = 0.82; all p < 0.0001) while the remaining diastolic parameters showed moderate correlation (e', r = 0.64; E/e', r = 0.54; left atrial volume index (LAVi), r = 0.61; all p < 0.0001). Classification of LV diastolic function by CMR showed good concordance with standardized grades established for TTE. CMR-based LV diastolic function may be integrated in routine clinical practice.Name of the registry: Technical Development of Cardiovascular Magnetic Resonance Imaging. Trial registration number: NCT00027170. Date of registration: November 26, 2001. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT00027170.