Thoracic Imaging 2003 - Society of Thoracic Radiology

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MONDAY 110 ventricular apex to access blood and with cannulation into the ascending aorta to return blood to the circulation (4). The HeartMate was the first implantable heart pump to gain Federal and Drug Administration approval to bridge patients to transplantation. The CardioVad In the early 1970’s, Adrian Kantrowitz implanted a pumping chamber similar to the intraaortic balloon into the wall of the descending aorta in three patients. Pneumatically driven by an external pump, the prosthesis was called the “dynamic aortic patch.” The clinical trial was terminated because of the problem of infection. Redesign and further animal studies have apparently solved the problem of sepsis caused by migration of bacteria along external tube tracts. A modified version of the Kantrowitz implantable pumping chamber, the CardioVad (LVAD Technology, Detroit, Mich.), is under development and clinical assessment has begun. Jarvik 2000 The Jarvik 2000 is a relatively new small axial continuous flow pump that is inserted into the left ventricle. A conduit carries the pumped blood to the descending thoracic aorta. Early trials show promise for long term assist with a low complication rate. The small size of the pump will be very helpful in children and smaller adults. Cardiomyoplasty The long-standing idea of using skeletal muscle to augment cardiac function has been tested clinically. Dynamic cardiomyoplasty is a surgical technique involving wrapping of the latissimus dorsi muscle around the heart to augment contractility. Electrodes powered by an implantable pulse generator induce cyclical contraction of the pedicled muscle (5). Alternatively, the muscle can be sewn into the left ventricular wall as a replacement for extensively damaged muscle. Dynamic aortoplasty, wrapping latissimus dorsi around the ascending aorta, has also shown promise in animals. An additional innovative experimental technique utilizes skeletal muscle wrapped around a pumping chamber implanted adjacent to the thoracic aorta. Muscle contraction is induced during cardiac diastole, the chamber is compressed, and diastolic pressure and flow are augmented as blood is squeezed out of the device. Biventricular Pacing Patients with moderate to severe heart failure with prolonged intraventricular conduction delay may have asynchronous ventricular contraction and a reduction in cardiac output. Prolonged PR intervals can also contribute to significant atrial-ventricular valve regurgitation. Pacing both right and left ventricles, biventricular pacing can significantly improve forward output, and atrioventricular pacing can reduce tricuspid and mitral valve regurgitation. Left ventricular pacing can be accomplished by mini-thoracotomy or thorascopic placement of left ventricular electrodes. A recent technologic development using a retrograde approach through the coronary sinus facilitates placement of electrodes in epicardial veins on the surface of the left ventricle (6). Total Artificial Heart (TAH) As of 1992, 116 TAH implants had been reported using at least eight different models, most commonly using the Symbion Jarvik-7 device (3). The Jarvik-7 incorporates two artificial ventricles that are attached to the native atria, the pulmonary artery and the aorta. Four disk-type artificial valves control blood flow direction. Each ventricle consists of a ridged housing separated into blood and air containing spaces by a polyurethane membrane. An external pneumatic pump connects to the airspace of each chamber by transthoracic polyurethane tubes. Pressurized air, cyclically driven into the pumping chamber, pumps the blood with sufficient cardiac output to totally support circulatory requirements. Radiographs show a radiolucent crescent inside each chamber during diastolic filling, whereas during systole, each air-containing chamber is completely filled producing two lucent globe-like structures (7). Total permanent replacement has not been successful because of complications including mechanical malfunction, thromboembolism, bleeding secondary to anticoagulation, infection from bacterial seeding along external tube tracts, and physical compression of adjacent anatomic structures, particularly pulmonary veins and inferior vena cava. Successful implantation of a permanent TAH remains a future goal. Recently, clinical trial of a new total artificial heart built by Abiomed was begun, although the results are too early to reach any conclusions. Respiratory Support Technology The need for technology to assist pulmonary gas exchange is another issue, particularly for patients with the adult respiratory distress syndrome (ARDS). ARDS has a reported mortality rate of 50 - 90% depending on group selection. Despite vigorous intensive care, the chances of survival have not significantly improved since the syndrome was first described. Patients with severe ARDS can be treated with artificial gas exchange devices while damaged lung recovers. Extracorporeal membrane oxygenation (ECMO) technology uses a synthetic semi-permeable membrane as a blood/gas interface for exchange of oxygen and carbon dioxide. Investigation of an implantable artificial lung for long term or even permanent respiratory support is underway. Extracorporeal Membrane Oxygenation (ECMO) Neonates with respiratory failure have been successfully managed with ECMO since 1975, reducing mortality rates from 85% to approximately 15%. This procedure has been modified and used for the treatment of adults (8). Using selection criteria which would predict a 90% risk of death, early trials report a reduction in mortality of approximately 50%. ECMO removes blood, perfuses it with oxygen and eliminates carbon dioxide, and returns blood to the patient. Two types of ECMO are used: veno-venous (VV) and veno-arterial (VA) (26). VV is used for pure respiratory support. Venous blood is drained from the right atrium by a cannula introduced into the right internal jugular vein or occasionally other large systemic veins. Oxygenated blood is reintroduced into a large peripheral vein, usually a femoral vein, or directly back into the right atrium by a double channel catheter. In VA bypass, venous blood is removed as in VV methods. Blood is returned to the arterial system by a cannula placed in the right internal carotid artery with the tip in the aortic arch. Sometimes the blood is returned to the femoral artery. VA ECMO is physiologically similar to cardiopulmonary bypass, providing both cardiovascular and pulmonary assist. Intravenous Oxygenator (IVOX) The IVOX device is a membrane oxygenator system configured as a complex of thin hollow fibers mounted on a catheter. The device is placed in the vena cava and venous blood circulates through the porous oxygenator while pure oxygen is sup-
plied to the hollow fibers by an external pump. A radiographic opaque stripe surrounded by gas lucency indicates its position on radiographs (9). Gas exchange capacity is limited compared to ECMO. The use of this device was discontinued after a short clinical trial. Future models are in development. Liquid Ventilation ARDS can be treated by perflourocarbon (PFC) liquid ventilation in two different ways: 1) Total liquid ventilation using a “liquid ventilator and 2) Partial liquid ventilation using a conventional mechanical gas ventilator. PFC liquid permits free exchange of oxygen and carbon dioxide while simultaneously expanding the lungs, eliminating atelectasis and washing debris from alveoli. The liquid is eliminated from the lungs by evaporation. The radiographic appearance of patients undergoing liquid ventilation is quite striking as the liquid is radiopaque (10). The Future The need for new effective methods of treatment for the thousands of patients with severe chronic intractable heart and lung failure is clear. New technological innovations may make permanent cardiopulmonary assist possible. Advances in miniaturization and transcutaneous energy systems will eventually completely eliminate the need for external connections. A different solution may evolve through research aimed at the development of genetically altered tissue surfaces of animal organs, thus providing an unlimited supply of hearts and/or lungs for transplantation. Stem cell research may yield methods of regenerating new myocardium, and research in organogenesis is showing early promise. REFERENCES O’Connell JB, Gunnar RM, Evans RW, et al. Task Force 1: Organization of heart transplantation in the U.S. JACC 1993; 22:8-64 Cascade PN, Rubenfire M, et al. Radiographic aspects of the phase-shift balloon pump. Radiology 1972;103:299-302 Locke T, McGregor C. Ventricular assist devices. In: Kay PH, ed. Techniques in Extracorporeal Circulation. Third edition. Oxford, England. Butterworth-Heinemann LTD. 1992:268-81 Emery RW, Joyce LD. Directions in cardiac assistance. Journal of Cardiac Surgery 1991;6:400-14 Nguyen TH, Hoang T-A, Dash N, et al. Latissimus dorsi cardiomyoplasty: radiographic findings. AJR 1988; 150:545-547 Cascade PN, Sneider MB, Koelling TM, Knight BP. The radiographic appearance of biventricular pacing for the treatment of heart failure. AJR 2001; 1447-1450 Fajardo LL, Standen JR, et al. Radiologic appearance of the Jarvik artificial heart implant and its thoracic complications. AJR 1988;151:667-71 Anderson III HL, Delius RE, et al. Early experience with adult extracorporeal membrane oxygenation in the modern era. Ann Thorac Surg 1992;53:553-63 Shukla PR, Snider MT, et al. Radiologic evaluation of the intravenous oxygenator. Radiology 1993;187:783-86 Kazerooni EA, Pranikoff T, Cascade PN. Partial liquid ventilation with perflubron during extracorporeal life support in adults: radiographic appearance. Radiology 1996; 198:137-142 111 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
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Sunday
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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 and 74: as well as separation of the cusps
Page 75 and 76: Pulmonary Veins: Imaging for Radiof
Page 77: Imaging of Cardiopulmonary Support
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
Page 91 and 92: 7. Crawford T, Yoon C, Wolfson K, e
Page 93 and 94: 80. Fleischmann D, Rubin GD, Bankie
Page 95 and 96: 127 MONDAY
Page 97 and 98: 129 MONDAY
Page 99 and 100: REFERENCES Bergin CJ, Rios G, King
Page 101 and 102: Notes 134
Page 103 and 104: March 4, 2003 General Session 7:00
Page 105 and 106: Adult Manifestations of Congenital
Page 107 and 108: will usually display the limbs of t
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
Page 119 and 120: Manpower Shortage in Radiology: Sol
Page 121 and 122: 159 TUESDAY
Page 127 and 128: 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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