Thoracic Imaging 2003 - Society of Thoracic Radiology

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MONDAY 106 Pulmonary Regurgitation Pulmonary valvular regurgitation usually results from severe pulmonary arterial hypertension. Less common causes include infectious endocarditis, carcinoid and syphilis. Chest radiograph and cross-sectional imaging shows findings of pulmonary arterial hypertension with enlargement of the central pulmonary arteries and dilatation of the right ventricle. Tricuspid Stenosis An uncommon lesion, tricuspid stenosis is usually associated with rheumatic heart disease and mitral stenosis. Carcinoid syndrome can cause tricuspid stenosis, in which case the pulmonary valve is usually involved, and typically there is a degree of tricuspid insufficiency. Prevalvular lesions such as right atrial myxoma and extension of renal cell carcinoma into the inferior vena cava and right atrium can also cause right atrial outflow obstruction. Patients typically present with fatigue due to decreased cardiac output, and symptoms of systemic venous hypertension such as hepatomegaly, ascites and peripheral edema. Chest radiograph and cross-sectional images will show signs of elevated systemic venous pressure with enlargement of the vena cavae, azygos vein and dilatation of the right atrium. Tricuspid Regurgitation In the majority of cases, tricuspid regurgitation is a result of right ventricular failure with dilatation of the tricuspid annulus. Less common causes include carcinoid tumor, infectious endocarditis, particularly in drug abusers, and rupture of the papillary muscle. If pulmonary venous hypertension is not present, tricuspid regurgitation may be well tolerated. If pulmonary venous hypertension is present, such as in patients with mitral valve disease, patients with tricuspid regurgitation develop symptoms of systemic venous hypertension. The chest radiograph and cross-sectional imaging will show right heart enlargement and dilatation of the azygos vein and vena cavae. CT scan with intravenous contrast may show reflux of contrast into the hepatic veins. REFERENCES Elliott LP. Cardiac imaging in infants, children and adults. Philadelphia, 1991, JB Lippincott Lester SJ, Heilbron B, Gin K, et al. The natural history and rate of progression of aortic stenosis. Chest 1998; 113:1109-1114 Lippert JA, White CS, Mason AC, Plotnick GD. Calcification of aortic valve detected incidentally on CT scans: Prevalence and clinical significance. Am J Roentgenol 1995; 164:73-77 Lipton MJ, Coulden R. Valvular heart disease. Radiol Clin N Am 1999; 37:319-339 Miller SW. Cardiac Radiology. St. Louis, 1996, Mosby-Year Book Sabet HY, Edwards WD. Tazelaar HD, Daly RC. Congenitally bicuspid aortic valves: A surgical pathology study of 542 cases and a literature review of 2,715 additional cases. Mayo Clin Proc 1999; 74:14-26 Schnyder PA, Sarraj AM, Duvoisin BE, et al. Pulmonary edema associated with mitral regurgitation: Prevalence of predominant involvement of the right upper lobe. Am J Roentgenol 1993; 161:33-36 Sorgato A, Faggiano P, Aurigemma GP, et al. Ventricular arrhythmias in adult aortic stenosis: Prevalence, mechanisms and clinical relevance. Chest 1998; 113:482-491
Pulmonary Veins: Imaging for Radiofrequency Ablation Procedures Michael B. Sneider, M.D. Atrial fibrillation is the most common sustained supraventricular arrhythmias and a major cause of stoke [1]. Abnormalities involving the pulmonary veins, such as arrhythmogenic foci within the vein walls from myocardial rests and venous dilatation, are frequent triggers of atrial fibrillation [1-3] and segmental ostial ablation of the pulmonary veins has been shown to be an effective treatment to prevent recurrences of atrial fibrillation [4, 5]. However, ablation with radiofrequency (RF) energy has been shown to be associated with risk of pulmonary vein stenosis [4, 6-9]. As catheter-directed pulmonary venography can potentially result in sub-optimal visualization of the pulmonary veins, pre-procedural mapping of the pulmonary venous anatomy is useful to define the position of the left atrial ostia, as well as defining the position and size of small accessory pulmonary veins which may be potentially arrhythmogenic [10]. While both magnetic resonance imaging and transesophageal ultrasound have been used to image the left atrium and pulmonary veins [8, 10], computed tomography (CT) is an excellent tool to define the pulmonary venous anatomy prior to ablation. CT can also be used as a sensitive tool with which to follow patients for postprocedural pulmonary vein stenosis [11, 12]. INDICATIONS AND TECHNIQUES OF RF ABLATION Indications: Typical indications for the use of RF ostial ablation are the presence of either paroxysmal or persistent atrial fibrillation, though the efficacy is lower in patients with persistent atrial fibrillation [5]. Atrial fibrillation is defined as persistent when present for greater than 30 days duration and requires cardioversion for termination. Techniques: While there are several different techniques for electrically isolating the pulmonary veins from the left atrium, they all involve placing electrode catheters under fluoroscopic guidance into the left atrium through a transseptal approach [13, 14]. Catheters are placed via the femoral vein in to the right atrium. The interatrial septum is then probed for a patent foramen ovale. If there is none, a needle septostomy is performed. Catheters are then extended into the left atrium. Selective pulmonary venography is used to road-map the individual pulmonary veins. Typically, as each individual pulmonary vein is probed, an electrical map is produced using a decapolar catheter with a distal ring configuration (Lasso catheter, Biosence Webster). When electrically conductive fascicles are identified, the pulmonary vein is electrically isolated by placing a catheter tipped with an RF thermistor into the vein, within 5 mm of the ostium. The wall of the pulmonary vein is then heated to 52ºC with multiple applications of 30-35 watts of energy, for up to 45 seconds duration per application [5]. There is a direct relationship between the ostial diameter and the duration of RF energy needed to achieve electrical isolation. Most patients will have multiple pulmonary veins treated. Isolation is best performed as close to the venoatrial junction as possible to avoid inducing venous stenosis and limit fibrillation recurrence from ostial remnants [15]. Patients are then maintained on anticoagulants for at least one month following the procedure. Some patients will undergo a repeat procedure should they continue to have fibrillation episodes. Techniques using cryoablation, rather than radiofrequency energy, are currently under investigation. CT PULMONARY VENOGRAPHY At our institution, all patients scheduled for pulmonary vein isolation undergo pre-procedural helical CT exams. Pulmonary vein anatomy and dimensions allow the electrophysiologist to select appropriately sized catheters and anticipate any anatomic variations or accessory veins. Three month follow-up CT exams are also performed to monitor for the development of pulmonary venous stenosis. Technique: CT examinations were initially preformed on a GE LightSpeed QX/i (GE Medical Imaging, Milwaukee, WI) four-row multidetector CT scanner. 150 cc (or 120 cc in patients under 120 lbs.) of Omnipaque 300 (Nycomed, Inc., Princeton, NJ) non-ionic intravenous contrast is power-injected at a rate of 4 cc/sec via a right antecubital vein. The scan is initiated with a delay of 30 seconds after beginning contrast injection. A collimation of 1.25 mm is used, reconstructed with a 0.6 mm interval. Currently, we use a GE LightSpeed16 (GE Medical Imaging) 16-row multidetector CT scanner with prospective ECG gating for reduced motion artifact. Scanning is performed from lung bases to the apices during a single breath-hold. This bottom-up direction minimizes respiratory motion should the patient inhale or exhale toward the end of the scan. For an average-sized adult male patient, the effective radiation dose per pulmonary vein scan, assuming 320 mA tube current, is approximately 10 mSv (1 rem). The dose is proportional to mAs, which is adjusted for the patient’s size (i.e., for the same time per rotation and 300 mA, the effective dose would be 10 mSv x (300/320) = 9.4 mSv). Three-dimensional pulmonary vein models: 3D models are constructed using volume analysis software from GE Medical Imaging on an Advantage Windows (GE Medical Imaging) workstation. Models are constructed to exclude surrounding structures such as the descending thoracic aorta, ribs, vertebral column and peripheral pulmonary arteries and veins. The models are best viewed from a posterior position with variable RPO and LPO angulations and dorsocranial tilt to avoid overlap with adjacent structures. Pulmonary vein diameters can be obtained in orthogonal planes. PULMONARY VEIN ANATOMY Normally, the right superior pulmonary vein drains the RUL and RML and the left superior pulmonary vein drains the LUL and lingula. The lower lobes are drained by their respective inferior pulmonary vein. In a recent series of 58 patients with atrial fibrillation [11], there were 4 separate pulmonary vein ostia in 47 patients (81%), three separate ostia in 2 patients (3%) due to a common origin of left superior and inferior pulmonary veins, and five separate ostia in 9 patients (16%) due to an accessory right middle pulmonary vein. The ostia of the inferior pulmonary veins tend to be more posterior and medial relative to the superior pulmonary veins. As measured by CT, the superior pulmonary veins tend to have a longer trunk (21.6 ± 107 MONDAY
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
Page 23 and 24: Sunday
Page 25 and 26: March 2, 2003 General Session Sunda
Page 27 and 28: SUNDAY 46 One type of direct-readou
Page 29 and 30: CT-PET Imaging Suzanne Aquino, M.D.
Page 31 and 32: SUNDAY 58 an accompanying decreased
Page 33 and 34: SUNDAY 60 Radiofrequency Ablation i
Page 35 and 36: SUNDAY 62 17. Sewell PE, Vance RB.
Page 37 and 38: SUNDAY 64 cal ventilation will be r
Page 39 and 40: SUNDAY 66 radiologic, and histopath
Page 41 and 42: SUNDAY 68 application. The untreate
Page 43 and 44: SUNDAY 70 The Expanded Spectrum of
Page 45 and 46: SUNDAY 72 Hypersensitivity Pneumoni
Page 47 and 48: SUNDAY 74 Small Airway Diseases Mic
Page 49 and 50: SUNDAY 76 The “Head-cheese Sign
Page 51 and 52: SUNDAY 78 “Holes” in the Lung:
Page 53 and 54: SUNDAY 80 Pleural Effusions Gerald
Page 55 and 56: SUNDAY 82 Asbestos Related Pleural
Page 57 and 58: SUNDAY 84 Other Pleural Neoplasms S
Page 59 and 60: SUNDAY 86 Image-Guided Therapy of M
Page 61 and 62: Notes 88
Page 63 and 64: March 3, 2003 General Session 7:00
Page 65 and 66: Cardiac MRI: Established Indication
Page 67 and 68: Cardiac MRI: New Developments Gauth
Page 69 and 70: 5. The volume of contrast medium re
Page 71 and 72: Acute Aortic Syndrome Ernest M. Sca
Page 73: as well as separation of the cusps
Page 77 and 78: Imaging of Cardiopulmonary Support
Page 79 and 80: plied to the hollow fibers by an ex
Page 81 and 82: swelling of the entire leg, calf sw
Page 83 and 84: Multi-channel Pulmonary CTA: New Te
Page 85 and 86: terminate scintigrams, CT correctly
Page 87 and 88: CT Strucural and Functional Imaging
Page 89 and 90: curves (TDCs) are generated by manu
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Page 93 and 94: 80. Fleischmann D, Rubin GD, Bankie
Page 95 and 96: 127 MONDAY
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Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
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Page 103 and 104: March 4, 2003 General Session 7:00
Page 105 and 106: Adult Manifestations of Congenital
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Page 109 and 110: Imaging of the Pericardium Paul L.
Page 111 and 112: Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114: TUESDAY 150 Nuclear Cardiology Upda
Page 115 and 116: TUESDAY 152 ties. The predominant 1
Page 117 and 118: TUESDAY 154 Imaging protocols: Util
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163 TUESDAY
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NIBIB Update for Thoracic Radiology
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vertically along the right atrium t
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Multidetector Pediatric Chest CT: P
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The Spectrum of Pulmonary Infection
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Immune deficiency occurs frequently
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TUESDAY 180 The Internet and the Pr
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TUESDAY 182 Workshop A1: Lymphoma:
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TUESDAY 184 Digital Images: Camera
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TUESDAY 186 Analysis of Mediastinal
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Unusual Manifestations of Lung Canc
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Wednesday
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March 5, 2003 General Session Wedne
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WEDNESDAY 208 principle is that “
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WEDNESDAY 210 years and a current o
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WEDNESDAY 212 lesions generally mim
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WEDNESDAY 214 capable of studying t
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WEDNESDAY 216 Small T1 Lung Cancer:
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WEDNESDAY 218 REFERENCES Seely JM,
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WEDNESDAY 220 Therefore, radiologis
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WEDNESDAY 222 sectional area varies
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WEDNESDAY 224 Lung Cancer Staging A
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Metastatic Disease to Lung Gordon L
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Thoracic Metastates from Osteosarco
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STR tutorial: Use of MD CT reconstr
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ogenic edema, fat embolism, heroin
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WEDNESDAY 236 Pulmonary Arterial Hy
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WEDNESDAY 238 pathological process,
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Thursday
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THURSDAY 250 Pulmonary Tuberculosis
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THURSDAY 252 1. Clinical criteria:
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THURSDAY 254 AIDS patients are also
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THURSDAY 256 Viral Infection on HRC
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THURSDAY 258 Imaging of Coccidioido
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THURSDAY 260 from the laryngeal sur
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THURSDAY 262 Inflammatory Diseases
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Virtual Endoscopy in the Thorax: Pr
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Notes 269 THURSDAY
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SECOND LEVEL THIRD LEVEL
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