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BACKGROUND: To evaluate whether volumetric iodine quantification of the lung allows for the automatic identification of patients with chronic thromboembolic pulmonary hypertension (CTEPH) and whether the extent of pulmonary malperfusion correlates with invasive hemodynamic parameters. METHODS: Retrospective data base search identified 30 consecutive patients with CTEPH who underwent CT pulmonary angiography (CTPA) on a spectral-detector CT scanner. Thirty consecutive patients who underwent an identical CT examination for evaluation of suspected acute pulmonary embolism and had no signs of pulmonary embolism or PH, served as control cohort. Lungs were automatically segmented for all patients and normal and malperfused volumes were segmented based on iodine density thresholds. Results were compared between groups. For correlation analysis between the extent of malperfused volume and mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) 3 patients were excluded because of a time span of more than 30 days between CTPA and right heart catheterization. RESULTS: Patients with CTEPH had a higher percentage of malperfused lung compared to controls (43.25%±24.72% vs. 21.82%±20.72%; P=0.001) and showed reduced mean iodine density in malperfused and normal-perfused lung areas, as well as in the vessel volume. Controls showed a left-tailed distribution of iodine density in malperfused lung areas while patients with CTEPH had a more symmetrical distribution (Skew: –0.382±0.435 vs. –0.010±0.396; P=0.004). Patients with CTEPH showed a significant correlation between the percentage of malperfused lung volume and the PVR (r=0.57, P=0.001). CONCLUSIONS: Volumetric iodine quantification helps to identify patients with CTEPH by showing increased areas of malperfusion. The extent of malperfusion might provide a measurement for disease severity in patients with CTEPH.

The aim of this study was to report outcomes following percutaneous microwave and cryoablation of lung metastases from adenoid cystic carcinoma (ACC) of the head and neck. This bi-institutional retrospective cohort study included 10 patients (6 females, median age 59 years [range 28–81]) who underwent 32 percutaneous ablation sessions (21 cryoablation, 11 microwave) of 60 lung metastases (median 3.5 tumors per patient [range 1–16]) from 2007 to 2019. Median tumor diameter was 16 mm [range 7–40], significantly larger for cryoablation (22 mm, p = 0.002). A median of two tumors were treated per session [range 1–7]. Technical success, local control, complications, and overall survival were assessed. Primary technical success was achieved for 55/60 tumors (91.7%). Median follow-up was 40.6 months (clinical) and 32.5 months (imaging, per tumor). Local control at 1, 2, and 3 years was 94.7%, 80.8%, and 76.4%, respectively, and did not differ between ablation modalities. Five of fifteen recurrent tumors underwent repeat ablation, and secondary technical success was achieved in four (80%). Assisted local tumor control at 1, 2, and 3 years was 96.2%, 89.8%, and 84.9%, respectively. Complications occurred following 24/32 sessions (75.0%) and 57.2% Common Terminology Criteria for Adverse Events (CTCAE) lower than grade 3. Of 13 pneumothoraces, 7 required chest tube placements. Hemoptysis occurred after 7/21 cryoablation sessions, and bronchopleural fistula developed more frequently with microwave (p = 0.037). Median length of hospital stay was 1 day [range 0–10], and median overall survival was 81.5 months (IQR 40.4–93.1). Percutaneous computed tomography-guided microwave and cryoablation can treat lung metastases from ACC of the head and neck. Complications are common but manageable, with full recovery expected.

Venous occlusion that affects the subclavian or innominate vein is a common problem in cardiac implantable electronic device (CIED) patients, with a reported range between 3% and 5%.1 In contrast, occlusion of the superior vena cava (SVC) not associated with malignancy (thus termed “benign”) is a rare condition (incidence 0.03%–0.15%) that causes a clinical syndrome of upper extremity and face swelling, pleural effusions, orthostatic hypotension, and collateral circulation and might even give rise to life-threatening complications if undetected, as illustrated by this case report.2,3

Radiological reports of pancreatic lesions are currently widely formulated as free texts. However, for optimal characterization, staging and operation planning, a wide range of information is required but is sometimes not captured comprehensively. Structured reporting offers the potential for improvement in terms of completeness, reproducibility and clarity of interdisciplinary communication. Interdisciplinary consensus finding of structured report templates for solid and cystic pancreatic tumors in computed tomography (CT) and magnetic resonance imaging (MRI) with representatives of the German Society of Radiology (DRG), German Society for General and Visceral Surgery (DGAV), working group Oncological Imaging (ABO) of the German Cancer Society (DKG) and other radiologists, oncologists and surgeons. Among experts in the field of pancreatic imaging, oncology and pancreatic surgery, as well as in a public online survey, structured report templates were developed by consensus. These templates are available on the DRG homepage under www.befundung.drg.de and will be regularly revised to the current state of scientific knowledge by the participating specialist societies and responsible working groups. This article presents structured report templates for solid and cystic pancreatic tumors to improve clinical staging (cTNM, ycTNM) in everyday radiology. · Structured report templates offer the potential of optimized radiological reporting with regard to completeness, reproducibility and differential diagnosis.. · This article presents consensus-based, structured reports for solid and cystic pancreatic lesions in CT and MRI.. · These structured reports are available open source on the homepage of the German Society of Radiology (DRG) under www.befundung.drg.de..· Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 - 655. In der klinischen Radiologie werden aktuell radiologische Befundberichte bei Pankreasläsionen weitverbreitet als Freitexte formuliert. Für die optimale klinische Versorgung, das Staging und die Operationsplanung sind mannigfaltige Informationen erforderlich, die mitunter nicht umfänglich erfasst werden. Die strukturierte Befundung bietet hier das Potenzial einer Verbesserung in Bezug auf Vollständigkeit, Reproduzierbarkeit sowie Klarheit der interdisziplinären Kommunikation. Interdisziplinäre Erstellung von strukturierten Befundvorlagen für solide und zystische Pankreastumoren in der Computertomografie (CT) und in der Magnetresonanztomografie (MRT) mit Vertretern der Deutschen Röntgengesellschaft (DRG), der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), der Arbeitsgemeinschaft Onkologische Bildgebung (ABO) der Deutschen Krebsgesellschaft (DKG) sowie weiteren Radiologen, Onkologen und Chirurgen. Unter Experten auf dem Gebiet der Pankreasbildgebung, onkologischen Versorgung und Pankreaschirurgie sowie in einer öffentlichen Online-Umfrage wurden strukturierte Befundvorlagen im Konsensus-Verfahren entwickelt, die im weiteren Verlauf regelmäßig durch die beteiligten Fachgesellschaften und verantwortlichen Arbeitsgemeinschaften auf den aktuellen Stand der wissenschaftlichen Erkenntnis angepasst werden sollen. Dieser Artikel stellt strukturierte Befundvorlagen für solide und zystische Pankreastumoren vor, die im radiologischen Alltag helfen sollen, das klinische Staging (cTNM, ycTNM) zu verbessern. · Strukturierte Befundvorlagen bieten das Potenzial einer optimierten radiologischen Befundung in Bezug auf Vollständigkeit, Reproduzierbarkeit und Differenzialdiagnose.. · Dieser Artikel stellt Konsensus-basierte, strukturierte Befundvorlagen für solide und zystische Pankreasläsionen im CT und MRT vor.. · Die von der Deutsche Röntgengesellschaft entwickelten Befundvorlagen werden unter www.befundung.drg.de zur Verfügung gestellt..· Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 – 656.

In multiple sclerosis (MS), the heterogeneous and numerous appearances of lesions may impair diagnostic accuracy. This study investigates if a combined automated co-registration and lesion color-coding method (AC) improves assessment of MS follow-up MRI compared with conventional reading (CR). We retrospectively assessed 70 follow-up MRI of 53 patients. Heterogeneous datasets of diverse scanners and institutions were used. Two readers determined presence of (a) progression, (b) regression, (c) mixed change, or (d) stable disease between the two examinations using corresponding FLAIR sequences in CR and AC-assisted reading. Consensus reference reading was provided by two blinded radiologists. Kappa statistics tested interrater agreement, McNemar’s test dichotomous variables, and Wilcoxon’s test continuous variables (statistical significance p ≤ 0.05). The cohort comprised 41 female and 12 male patients with a mean age of 40 (± 14) years. Average rating time was reduced from 78 (± 36) to 44 (±22) s with the AC approach (p

To evaluate the value of spectral-detector CT (SDCT) in the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), its differentiation against other etiologies of pulmonary hypertension (PH) and in the prediction of disease severity.60 patients with suspected PH underwent SDCT. Additional diagnostic tests in accordance with the ESC guidelines including right heart catherization and VQ-SPECT were performed. After full diagnostic work-up patients were classified as: 21 precapillary PH, 5 postcapillary PH, 6 combined pre- and postcapillary PH, 19 CTEPH, 9 no PH. SDCT examinations were analyzed by two blinded readers deciding on the diagnosis of CTEPH and scoring the extent of perfusion abnormalities on iodine density images. An additional reading was performed using conventional CTPA images only.With access to SDCT data, both readers reached a sensitivity of 100% for the diagnosis of CTEPH with a specificity of 95.1% and 87.8%. On analysis of conventional CTPA images alone, specificity and diagnostic confidence decreased for both readers (Specificity 90.2 and 85.3%) while sensitivity dropped for the less experienced reader only (Sensitivity 78.9%). Patients with PH showed significantly more perfusion abnormalities than patients without PH (16.6 ± 8.4 vs. 9.5 ± 8.9 p 0.001) and the extent of perfusion abnormalities correlated with the mean pulmonary artery pressure (r = 0.37 p = 0.008).SDCT offers confident identification of patients with CTEPH and enables a comprehensive analysis of pulmonary vasculature, pulmonary perfusion and the lung parenchyma in a single examination for patients with suspected PH.

ObjectiveLiver cancer is one of the most commonly diagnosed cancer, and energy-based tumor ablation is a widely accepted treatment. Automatic and robust segmentation of liver tumors and ablation zones would facilitate the evaluation of treatment success. The purpose of this study was to develop and evaluate an automatic deep learning based method for (1) segmentation of liver and liver tumors in both arterial and portal venous phase for pre-treatment CT, and (2) segmentation of liver and ablation zones in both arterial and portal venous phase for after ablation treatment.Materials and Methods252 CT images from 63 patients undergoing liver tumor ablation at a large University Hospital were retrospectively included; each patient had pre-treatment and post-treatment multi-phase CT images. 3D voxel-wise manual segmentation of the liver, tumors and ablation region by the radiologist provided reference standard. Deep learning models for liver and lesion segmentation were initially trained on the public Liver Tumor Segmentation Challenge (LiTS) dataset to obtain base models. Then, transfer learning was applied to adapt the base models on the clinical training-set, to obtain tumor and ablation segmentation models both for arterial and portal venous phase images. For modeling, 2D residual-attention Unet (RA-Unet) was employed for liver segmentation and a multi-scale patch-based 3D RA-Unet for tumor and ablation segmentation.ResultsOn the independent test-set, the proposed method achieved a dice similarity coefficient (DSC) of 0.96 and 0.95 for liver segmentation on arterial and portal venous phase, respectively. For liver tumors, the model on arterial phase achieved detection sensitivity of 71%, DSC of 0.64, and on portal venous phase sensitivity of 82%, DSC of 0.73. For liver tumors >0.5cm3 performance improved to sensitivity 79%, DSC 0.65 on arterial phase and, sensitivity 86%, DSC 0.72 on portal venous phase. For ablation zone, the model on arterial phase achieved detection sensitivity of 90%, DSC of 0.83, and on portal venous phase sensitivity of 90%, DSC of 0.89.ConclusionThe proposed deep learning approach can provide automated segmentation of liver tumors and ablation zones on multi-phase (arterial and portal venous) and multi-time-point (before and after treatment) CT enabling quantitative evaluation of treatment success.

Background Endovascular treatment can be a fast and safe option in the case of acute, internal bleeding – but it requires special knowledge and technical skills. Interventionalists must consider the anatomy and potential complications. As in this case report, the anterior spinal artery, for example, can be a crucial vessel that must always be considered when embolizing intercostal or lumbar arteries. The risk of spinal ischemia has to be taken into account and should be minimized by choosing the appropriate treatment option. Case presentation We report about a 77 year old, male patient with upper gastrointestinal bleeding after esophagectomy and gastric conduit reconstruction. A CT scan identified a pseudoaneurysm of an intercostal artery penetrating the gastric conduit as the bleeding source. In the DSA, a direct connection between the intercostal artery and the anterior spinal artery appeared to be likely. Due to the associated risk of spinal ischemia, an embolization of the intercostal artery was not an option. We decided to implant a stentgraft that would stop the perfusion of the pseudoaneurysm, but preserve the perfusion of the intercostal artery. Due to the small diameter of the vessel, we could not implant our commonly used stentgrafts in this case. Therefore, we chose an uncommon solution and used a stentgraft that is designed primarily for coronary arteries. Conclusions Whenever intercostal or lumbar arteries need to be embolized, a possible connection to the anterior spinal artery must be considered and interventionalists have to be aware of possible ischemic complications. In this case, a stentgraft designed primarily for coronary arteries offered a good endovascular treatment option for the pseudoaneurysm of an intercostal artery. The risk of spinal ischemia could be minimized by using this stentgraft.

Background Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) represents the gold standard for assessment of myocardial viability. The purpose of this study was to investigate the clinical potential of Compressed SENSE (factor 5) accelerated free-breathing three-dimensional (3D) whole heart LGE with high isotropic spatial resolution (1.4 mm3 acquired voxel size) compared to standard breath-hold LGE imaging. Methods This was a retrospective, single-center study of 70 consecutive patients (45.8 ± 18.1 years, 27 females; February–November 2019), who were referred for assessment of left ventricular myocardial viability and received free-breathing and breath-hold LGE sequences at 1.5 T in clinical routine. Two radiologists independently evaluated global and segmental LGE in terms of localization and transmural extent. Readers scored scans regarding image quality (IQ), artifacts, and diagnostic confidence (DC) using 5-point scales (1 non-diagnostic—5 excellent/none). Effects of heart rate and body mass index (BMI) on IQ, artifacts, and DC were evaluated with ordinal logistic regression analysis. Results Global LGE (n = 33) was identical for both techniques. Using free-breathing LGE (average scan time: 04:33 ± 01:17 min), readers detected more hyperenhanced lesions (28.2% vs. 23.5%, P Conclusions In a clinical setting, free-breathing Compressed SENSE accelerated 3D high isotropic spatial resolution whole heart LGE provides good to excellent image quality in 80% of scans independent of heart rate while enabling improved depiction of small and particularly non-ischemic hyperenhanced lesions in a shorter scan time than standard breath-hold LGE.

Background In order to efficiently perform laparoscopic microwave ablation of liver tumours precise positioning of the ablation probe is mandatory. This study evaluates the precision and ablation accuracy using the innovative laparoscopic stereotactic navigation system CAS-One-SPOT in comparison to 2d ultrasound guided laparoscopic ablation procedures. Methods In a pig liver ablation model four surgeons, experienced (n = 2) and inexperienced (n = 2) in laparoscopic ablation procedures, were randomized for 2d ultrasound guided laparoscopic or stereotactic navigated laparoscopic ablation procedures. Each surgeon performed a total of 20 ablations. Total attempts of needle placements, time from tumor localization till beginning of ablation and ablation accuracy were analyzed. Results The use of the laparoscopic stereotactic navigation system led to a significant reduction in total attempts of needle placement. The experienced group of surgeons reduced the mean number of attempts from 2.75 ± 2.291 in the 2d ultrasound guided ablation group to 1.45 ± 1.191 (p = 0.0302) attempts in the stereotactic navigation group. Comparable results could be observed in the inexperienced group with a reduction of 2.5 ± 1.50 to 1.15 ± 0.489 (p = 0.0005). This was accompanied by a significant time saving from 101.3 ± 112.1 s to 48.75 ± 27.76 s (p = 0.0491) in the experienced and 165.5 ± 98.9 s to 66.75 ± 21.96 s (p Conclusion The use of a stereotactic navigation system for laparoscopic microwave ablation procedures of liver tumors significantly reduces the attempts and time of predicted correct needle placement for novices and experienced surgeons without impairing the accuracy of the ablation procedure.

Severe aortic stenosis (AS) is known to be associated with substantial myocardial remodelling, leading to diffuse myocardial fibrosis (DMF). Native myocardial T1 is emerging as a novel imaging biomarker for the non-invasive assessment of DMF. In contrast, no studies exist elucidating changes of myocardial T2 reflecting myocardial oedema in the presence of AS. The purpose of the present study was to combine native T1 and T2 mapping in order to characterize myocardial tissue changes in the setting of severe AS.After obtaining ethical approval and informed consent, a total of 26 prospectively selected patients with severe AS (13 women, mean age 81 ± 7 years) and 17 healthy controls (12 women, mean age 63 ± 6 years) underwent cardiac magnetic resonance (CMR) imaging on a clinical 3 T scanner. The CMR protocol included a native Modified Look-Locker (MOLLI) T1 mapping and a Gradient Spin Echo (GraSE) T2-mapping sequence in three short-axis slices and one long-axis view. After segmentation, myocardial T1 and T2 values were averaged over the entire myocardium. Statistical analysis was performed using Wilcoxon sum-rank test, Welch's independent t-test and Pearson's correlation coefficient.Global native myocardial T1 was significantly increased in AS patients when compared to controls (1305 ± 39 vs. 1272 ± 21 ms, p = .005). Similarly, mean myocardial T2 was significantly elevated in AS patients (51 ± 4 vs. 46 ± 2 ms, p .001) and showed a strong correlation with native T1 (r = .60, p .001). An overlap was observed between T1 of both groups, whereas T2 discriminated nearly perfectly between the two groups (area under the curve in ROC analyses: 0.76 for T1, 0.87 for T2).Patients with severe AS exhibit significantly elevated native myocardial T1, which has previously been shown to correlate with the amount of myocardial collagen. Adding to this evidence, the present study is the first to show that native T1 and T2 are both significantly elevated and correlated in AS patients, pointing towards a potential role of oedematous/inflammatory processes in the pathophysiology of myocardial remodelling associated with AS.

Die Inzidenz primarer Lebertumoren steigt. Moderne minimal-invasive bildgestutzte Verfahren ermoglichen eine Therapie mit kurativem Ansatz. Ziel der Arbeit ist es, die Vielzahl der bildgestutzten minimal-invasiven Verfahren bezuglich der Evidenz in Bezug auf die lokale Tumorkontrolle und das Gesamtuberleben darzustellen. MEDLINE-Recherche zum Thema hepatozellulares Karzinom (HCC), minimal-invasive Therapie, lokal ablative Therapie, Therapiestratifizierung, vergleichende Studien. Der Evidenzgrad unterscheidet sich sehr stark in Abhangigkeit von den betrachteten Verfahren. Die besten Daten inklusive prospektiv randomisierter Studien liegen fur die Radiofrequenzablation (RFA) des HCC vor. Die RFA ist den anderen ablativen Verfahren bezuglich Tumorkontrolle und Gesamtuberleben uberlegen. Im Vergleich zwischen RFA und chirurgischer Resektion liegen randomisierte Studien mit widerspruchlichen Ergebnissen vor. Die Mikrowellenablation und robotische stereotaktische Bestrahlung zeigten in retrospektiven Studien im Vergleich zur RFA und Chirurgie genug Potenzial, um die Techniken in randomisierten Studien zu bestatigen. Fur den „high intensity focused ultrasound“ (HIFU) und die irreversible Elektroporation liegen nur anekdotische Daten vor. Die perkutane Ethanolinjektion (PEI), die Kryoablation und die „laser-induced thermal therapy“ (LITT) sind in Studien der RFA unterlegene Techniken. Auf dem Boden einer strukturierten radiologischen Bildgebung und Befundung konnen eine minimal-invasive Resektion und lokal ablative Techniken die Prognose beim HCC auch uber das Stadium BCLC 0/A hinaus verbessern.

Purpose/introduction This study aims to evaluate the incremental diagnostic value of cardiac magnetic resonance (CMR) feature tracking (FT) derived atrial and ventricular strain-analysis in patients with acute myocarditis (myocarditis) as an additional tool to established Lake-Louise criteria (LLC). Material and methods A total of 86 patients with clinically proven myocarditis and 30 healthy controls underwent a comprehensive CMR protocol. In addition to established LLC, FT derived strain parameters from the left (LA) and right atrium (RA) as well as the left (LV) and right ventricle (RV) were assessed. Receiver operating characteristics analysis was performed to compare diagnostic performance. Results Patients with myocarditis showed significantly reduced LA passive strain (LA e e : 26.3 ± 14.5 vs. 33.5 ± 10.1%, p = .007), LA peak early negative strain rate (LA SRe: −1.94 ± 0.59 1/s vs. −1.46 ± 0.62 1/s, p Conclusion Combining quantitative CMR derived atrial and ventricular strain parameters with established LLC parameters can improve the diagnostic performance in patients with suspected myocarditis, including those with preserved LV function. Further investigations should focus on LA function, which appears to be more sensitive to early functional changes than LV function.

BACKGROUND 4D flow imaging can be used to evaluate vortex formation in the pulmonary artery seen in patients with pulmonary hypertension. We evaluated if a k-t accelerated multi-VENC (velocity encoding) 4D flow acquisition improves image quality, inter-reader agreement and correlation with hemodynamic parameters. METHODS A total of 14 patients with pulmonary hypertension (5 females, 9 males; mean age 61 ± 16 years) underwent 4D flow MRI (magnetic resonance imaging) and right heart catheterization. In addition to that, 13 healthy volunteers (2 females, 11 males, mean age 33 ± 12 years) also underwent 4D flow MRI. Multi- and single-VENC datasets were reconstructed and evaluated for vortex formation and vortex duration by two blinded readers and image quality was rated on a 5-point scale. RESULTS Both readers rated image quality as significantly higher on multi-VENC datasets (3.96 ± 0.71 vs. 2.56 ± 0.93, p

Background Non-invasive evaluation of coronary stent patency by coronary computed tomography angiography (cCTA) remains challenging. Multiple studies showed that CT technology but also individual stent design strongly influence the assessability of coronary stents by cCTA. Purpose To expand the available data on cCTA characteristics of coronary stents by 24 novel types to help interpreting examinations of patients after stent placement and selecting which stents are suitable for assessment by cCTA. Material and Methods Twenty-four novel coronary stents (17 cobalt–chromium, six stainless-steel, one platinum–chromium) were examined in a coronary phantom. Standard cCTA parameters with stent-specific algorithms were used. Image quality was quantified for each stent using established parameters (in-stent attenuation alteration and visible lumen diameter). Results Most stents (n = 14) showed lumen visibilities of 45–55%. No severe restriction of lumen visibility (>60%) was found. The majority of stents (n = 13) caused only small intraluminal attenuation deviations and no severe alterations (>20%) were found. When grouped by manufacturing material, no significant differences were found between cobalt–chromium and stainless-steel with identical mean visible diameters (1.52 ± 0.17 mm vs. 1.52 ± 0.13 mm) and comparable attenuation alterations (35.04 ± 16.56 HU vs. 21.25 ± 14.60 HU). The only platinum–chromium stent showed a smaller visible diameter (1.23 mm) and higher attenuation alteration (41.70 HU), but was also deemed to be assessable by cCTA. Conclusion All 24 novel evaluated stents are eligible for non-invasive evaluation by cCTA without significant differences between cobalt–chromium and stainless-steel stents. This updated catalogue of CT appearances of current coronary stents may serve as reference when taking care of patients with stents in need of coronary imaging.

Objective To evaluate the influence of monoenergetic reconstructions using a spectral detector CT (SDCT) on the computer aided detection (CAD) of pulmonary artery embolism (PAE) on CT pulmonary angiography (CTPA) and CT in venous contrast phase (CTV). Material and Methods A retrospective data base search identified 15 patients with CTPA and 18 patients with CTV and diagnosis of PAE. For these patients, monoenergetic (monoE) images at different energy levels or with a fixed attenuation in the pulmonary artery were generated and independently analyzed using a commercially available computer aided detection (CAD) tool. Attenuation in the pulmonary artery and in the embolus was measured. Results For CTPA and CTV, in monoenergetic images the difference in attenuation between vessel and embolus was significantly higher than in conventional images. In CTPA the detection rate was highest in the >500 HU monoE images with 67,9% detected emboli and 93,3% of patients correctly identified as having PAE. At the same time the false positive rate could be significantly reduced by using monoE images compared to conventional images. Detection rates for CTV were lower than in CTPA but were raised significantly by monoE reconstructions. Conclusions The combination of SDCT and CAD improves the diagnostic accuracy of CAD and enables CAD interpretation of CTV.

Background: The aim of this study was to evaluate the diagnostic potential of a novel cardiovascular magnetic resonance (CMR) based multiparametric imaging approach in suspected myocarditis and to compare it to traditional Lake Louise criteria (LLC). Methods: CMR data from 67 patients with suspected acute myocarditis were retrospectively analyzed. Seventeen age- and gender-matched healthy subjects served as control. T2-mapping data were acquired using a Gradient-Spin-Echo T2-mapping sequence in short-axis orientation. T2-maps were segmented according to the 16-segments AHA-model and segmental T2 values and pixel-standard deviation (SD) were recorded. Afterwards, the parameters maxT2 (the highest segmental T2 value) and madSD (the mean absolute deviation (MAD) of the pixel-SDs) were calculated for each subject. Cine sequences in three long axes and a stack of short-axis views covering the left and right ventricle were analyzed using a dedicated feature tracking algorithm. Results: A multiparametric imaging model containing madSD and LV global circumferential strain (GCSLV) resulted in the highest diagnostic performance in receiver operating curve analyses (area under the curve [AUC] 0.84) when compared to any model containing a single imaging parameter or to LLC (AUC 0.79). Adding late gadolinium enhancement (LGE) to the model resulted in a further increased diagnostic performance (AUC 0.93) and yielded the highest diagnostic sensitivity of 97% and specificity of 77%. Conclusions: A multiparametric CMR imaging model including the novel T2-mapping derived parameter madSD, the feature tracking derived strain parameter GCSLV and LGE yields superior diagnostic sensitivity in suspected acute myocarditis when compared to any imaging parameter alone and to LLC. © 2017 The Author(s).

To re-evaluate a recently suggested approach of quantifying myocardial oedema and increased tissue inhomogeneity in myocarditis by T2-mapping. Cardiac magnetic resonance data of 99 patients with myocarditis were retrospectively analysed. Thirthy healthy volunteers served as controls. T2-mapping data were acquired at 1.5 T using a gradient-spin-echo T2-mapping sequence. T2-maps were segmented according to the 16-segments AHA-model. Segmental T2-values, segmental pixel-standard deviation (SD) and the derived parameters maxT2, maxSD and madSD were analysed and compared to the established Lake Louise criteria (LLC). A re-estimation of logistic regression models revealed that all models containing an SD-parameter were superior to any model containing global myocardial T2. Using a combined cut-off of 1.8 ms for madSD + 68 ms for maxT2 resulted in a diagnostic sensitivity of 75% and specificity of 80% and showed a similar diagnostic performance compared to LLC in receiver-operating-curve analyses. Combining madSD, maxT2 and late gadolinium enhancement (LGE) in a model resulted in a superior diagnostic performance compared to LLC (sensitivity 93%, specificity 83%). The results show that the novel T2-mapping-derived parameters exhibit an additional diagnostic value over LGE with the inherent potential to overcome the current limitations of T2-mapping. • A novel quantitative approach to myocardial oedema imaging in myocarditis was re-evaluated. • The T2-mapping-derived parameters maxT2 and madSD were compared to traditional Lake-Louise criteria. • Using maxT2 and madSD with dedicated cut-offs performs similarly to Lake-Louise criteria. • Adding maxT2 and madSD to LGE results in further increased diagnostic performance. • This novel approach has the potential to overcome the limitations of T2-mapping.

Purpose To evaluate the correlation between left atrial diverticula (LAD) and left-sided septal pouches (LSSP) with ischemic brain alterations in MRI. Methods A retrospective analysis of 174 patients who received both, a dedicated cardiac CT angiography (CCTA) and a brain MRI examination was performed. Two radiologists independently reviewed all examinations for the presence of LAD and LSSP as well as ischemic alterations of the brain. Subsequently, the correlation between these cardiac and cerebral findings as well as to other potentially related risk factors was assessed. Results 71 LAD (total prevalence 41%) and 65 LSSP (total prevalence 37%) were identified in 174 patients. Combined prevalence was 10%. Ischemic brain alterations were found in patients with a LAD in 42.3% (30/71) and with a LSSP in 64.6% (42/65). Patients without any anatomical variant in the left atrium showed ischemic brain alterations in 39.4% (26/66). The presence of a LSSP was associated with an increased risk for ischemic brain alterations in multivariate logistic regression analysis after adjusting for other risk factors (OR = 3.57, 95% CI = 0.51–2.09, p Conclusion In our study cohort LAD and LSSP are highly prevalent anatomical structures within the left atrium. Patients with LSSP showed an approximated 3.5-fold higher probability for ischemic brain alterations. Therefore, LSSP should be considered as a potential risk factor for cardioembolic strokes and its presence should be stated in cardiac CT reports.

Patients with Congenital heart disease (CHD) require repetitive imaging of the pulmonary vasculature throughout their life. In this study, we compared a novel Compressed SENSE accelerated (factor 9) electrocardiogram (ECG)- and respiratory-triggered 3D modified Relaxation-Enhanced Angiography without Contrast and Triggering (modified REACT-non-contrast-enhanced magnetic resonance angiography (modified REACT-non-CE-MRA)) with standard non-ECG-triggered time-resolved 4D CE-MRA for imaging of the pulmonary arteries and veins in patients with CHD.This retrospective analysis of 25 patients (June 2018-April 2019) with known or suspected CHD was independently conducted by two radiologists executing measurements on modified REACT-non-CE-MRA and 4D CE-MRA on seven dedicated points (inner edge): Main pulmonary artery (MPA), right and left pulmonary artery, right superior and inferior pulmonary vein, left superior (LSPV) and inferior pulmonary vein. Image quality for arteries and veins was evaluated on a four-point scale in consensus.Twenty-three of the 25 included patients presented a CHD. There was a high interobserver agreement for both methods of imaging at the pulmonary arteries (ICC ≥ 0.96); at the pulmonary veins, modified REACT-non-CE-MRA showed a slightly higher agreement, pronounced at LSPV (ICC 0.946 vs. 0.895). Measurements in 4D CE-MRA showed higher diameter values compared to modified REACT-non-CE-MRA, at the pulmonary arteries reaching significant difference (e.g. MPA: mean 0.408 mm, p = 0.002). Modified REACT-non-CE-MRA (average acquisition time 07:01 ± 02:44 min) showed significant better image quality than 4D CE-MRA at the pulmonary arteries (3.84 vs. 3.32, p 0.001) and veins (3.32 vs. 2.72, p = 0.015).Compressed SENSE accelerated (factor 9) ECG- and respiratory-triggered 3D modified REACT-non-CE-MRA allows for reliable and fast imaging of the pulmonary arteries and veins with higher image quality and slightly higher interobserver agreement than 4D CE-MRA without contrast agent and associated disadvantages. Therefore, it represents a clinically suitable technique for patients requiring repetitive imaging of the pulmonary vasculature, e.g. patients with CHD.

Structured reports have numerous benefits through standardizing the way imaging findings are reported and communicated. Nevertheless, the adoption of structured reports in everyday radiological practice is still limited. In view of the irrefutable benefits, various national and international radiological societies have started initiatives which aim at promoting a broader use of structured reports. Up to now, no consented templates in German language existed for the reporting of cross-sectional imaging studies of the heart. Upon invitation of the working group for Cardiovascular Imaging of the German Society of Radiology a panel of radiologists, cardiologists, pediatric cardiologists and cardiothoracic surgeons, experts on the field of cardiovascular imaging and structured reporting, met for two interdisciplinary consensus meetings at the University Hospital Cologne in 2018. The aim of these meetings was to develop and agree on templates for the reporting of MR and CT studies of various cardiovascular disease entities. During the meetings the panel of experts developed and reached consensus on 11 different templates for the structured reporting of the following: myocarditis, dilated cardiomyopathy, hypertrophic (obstructive) cardiomyopathy, arrythmogenic right ventricular cardiomyopathy, siderosis, ischemia and vitality imaging, tetralogy of Fallot, aortic coarctation, coronary CT and CT for Transcatheter Aortic Valve Implantation (TAVI) planning. The first five templates are presented in this publication and are currently being transferred to a HTML 5/IHR MRRT compatible format. Subsequently, the templates will be made available for free use on the website www.befundung.drg.de. For the first time, consented templates in German language for the structured reporting of cross-sectional imaging studies of the heart are presented. These templates are aimed at providing a constant level of high reporting quality and increasing the efficiency of the generation and communication of imaging reports. · Structured reporting offers numerous benefits by standardizing generation and communication of imaging reports.. · For the first time templates in German language for the structured reporting of CMR imaging studies of cardiomyopathies are presented. · These templates will be made available on the website www.befundung.drg.de and can be commented via agit-sr@googlegroups.com..· Bunck AC, Baeßler B, Ritter C et al. Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Cardiomyopathies (Myocarditis, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular cardiomyopathy and Siderosis). Fortschr Röntgenstr 2020; 192: 27 - 37. Strukturierte Befundung bietet viele Vorteile in der Standardisierung der Befunderstellung und -kommunikation und bildet dennoch bisher die Ausnahme im radiologischen Alltag. Den Einsatz der strukturierten Befundung zu fördern ist daher erklärtes Ziel nationaler und internationaler radiologischer Gesellschaften. Bisher existierten für den deutschsprachigen Raum keine konsentierten Befundvorlagen auf dem Gebiet der kardialen Schnittbilddiagnostik. Auf Einladung der AG Herz- und Gefäßdiagnostik der Deutschen Röntgengesellschaft fanden an der Uniklinik Köln im Jahr 2018 zwei interdisziplinäre Konsensus-Treffen zwischen Experten der kardiovaskulären Bildgebung und strukturierten Befundung aus den Fachrichtungen Radiologie, Kardiologie, Kinderkardiologie und Thorax-, Herz- und Gefäßchirurgie statt. Ziel der Treffen war es, im interdisziplinären Diskurs Befundvorlagen zur bildgebenden CT- und MR-Diagnostik verschiedener Krankheitsbilder und Untersuchungen des Herzens gemeinsam zu erarbeiten. Im Rahmen der beiden Treffen wurden Vorlagen zu folgenden Krankheitsbildern und Untersuchungen entwickelt und im Konsens verabschiedet: Myokarditis, dilatative Kardiomyopathie, hypertrophe (obstruktive) Kardiomyopathie, arrhythmogene rechtsventrikuläre Kardiomyopathie (ARVC), Siderose, Ischämie- und Vitalitätsdiagnostik, Fallot’sche Tetralogie, Aortenisthmusstenose, Koronar-CT und TAVI-CT. Die 5 erstgenannten Vorlagen sind Gegenstand der vorliegenden Publikation und werden aktuell von der AG für Informationstechnologie (AGIT) der DRG in ein HTML-5/IHE-MRRT-konformes Format überführt. Anschließend werden die Vorlagen auf der Seite www.befundung.drg.de zur freien Nutzung bereitgestellt werden. Im Rahmen der vorliegenden Publikation werden erstmals interdisziplinär konsentierte deutschsprachige Befundvorlagen für die Schnittbilddiagnostik des Herzens vorgeschlagen. Der Einsatz der erarbeiteten Vorlagen soll helfen, für eine gleichbleibend hohe Befundungsqualität zu sorgen und die Effizienz der Befunderstellung und -kommunikation zu steigern. · Strukturierte Befundung bietet viele Vorteile in der Standardisierung der Befunderstellung und -kommunikation.. · Erstmals wurden Befundvorlagen in deutscher Sprache für die MRT-Diagnostik von Kardiomyopathien erarbeitet.. · Die Vorlagen werden unter www.befundung.drg.de bereitgestellt und können über agit-sr@googlegroups.com kommentiert werden..· Bunck AC, Baeßler B, Ritter C et al. Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Cardiomyopathies (Myocarditis, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular cardiomyopathy and Siderosis). Fortschr Röntgenstr 2020; 192: 27 – 37.

In-stent restenosis (ISR) is one of the main long-term complications after coronary stent placement, and the ability to evaluate ISR noninvasively using coronary computed tomography (CT) angiography remains challenging. For this application, spectral photon-counting CT (SPCCT) has the potential to increase image quality and reduce artifacts due to its advanced detector technology.Our study aimed to verify the technical and clinical potential of a novel SPCCT prototype using an ISR phantom setup.Soft plaque-like restenosis (45 HU; approximately 50% of the stent lumen) were inserted into 10 different coronary stents (3 mm diameter), which were placed in a vessel phantom and filled with a contrast agent (400 HU). A research prototype SPCCT and a clinical dual-layer CT (DLCT; IQon; Philips) with comparable acquisition and reconstruction parameters were used to scan the phantoms. Conventional polyenergetic (PolyE) and monoenergetic (MonoE) images with 4 different energy levels (40, 60, 90, 120 keV) were reconstructed. Qualitative (delineation of the stenosis and adjacent residual lumen using a 5-point Likert scale) and quantitative (image noise, visible lumen diameter, lumen diameter adjacent to the stenosis, contrast-to-noise ratio of the restenosis) parameters were evaluated for both systems.The qualitative results averaged over all reconstructions were significantly superior for SPCCT compared with DLCT (eg, subjective rating of the best reconstruction of each scanner: DLCT PolyE: 2.80 ± 0.42 vs SPCCT MonoE 40 keV: 4.25 ± 1.03). Stenosis could be clearly detected in 9 and suspected in 10 of the 10 stents with both SPCCT and DLCT. The residual lumen next to the stenosis was clearly delineable in 7 of 10 stents (0.64 ± 0.11 mm or 34.97% of the measured stent lumen) with SPCCT, while it was not possible to delineate the residual lumen for all stents using DLCT. The measured diameter of the lumen within the stent was significantly higher for SPCCT compared with DLCT in all reconstructions with the best results for the MonoE 40 keV images (SPCCT: 1.80 ± 0.17 mm; DLCT: 1.50 ± 0.31 mm). The image noise and the contrast-to-noise ratio were better for DLCT than for SPCCT (contrast-to-noise ratio: DLCT MonoE 40: 31.58 ± 12.54; SPCCT MonoE 40: 4.64 ± 1.30).Spectral photon-counting CT allowed for the noninvasive evaluation of ISR with reliable results regarding the residual lumen for most tested stents and the clear identification or suspicion of stenosis for all stents. In contrast, the residual lumen could not be detected for a single stent using DLCT.

Aims: To compare the effects of long-term treatment with the GLP-1RA exenatide twicedaily versus titrated insulin glargine (iGlar) on renal function and albuminuria in type 2 diabetes (T2DM) patients. Methods: We post-hoc evaluated renal outcome-data of 54 overweight T2DM patients (mean +/- SD age 60 +/- 8 years, HbA1c 7.5 +/- 0.9%, eGFR 86 +/- 16 mL/min/1.73m(2), median [IQR] urinary albumin-to-creatinine-ratio (UACR) 0.75 [0.44-1.29] mg/mmol) randomised to exenatide 10 mg twice-daily or titrated iGlar on-top-of metformin for 52-weeks. Renal efficacy endpoints were change in creatinine clearance (CrCl) and albuminuria (urinary albuminexcretion [UAE] and UACR) based on 24-h urines, collected at baseline and Week-52. eGFR and exploratory endpoints were collected throughout the intervention-period, and after a 4-week wash-out. Results: HbA1c-reductions were similar with exenatide (mean +/- SEM -0.80 +/- 0.10%) and iGlar (-0.79 +/- 0.14%; treatment-difference 0.02%; 95% CI - 0.31 to 0.42%). Change from baseline to Week-52 in CrCl, UAE or UACR did not statistically differ; only iGlar reduced albuminuria (P

Accurate assessment of coronary stents using non-invasive CT imaging remains challenging despite new stent materials and improvements in CT technology. Virtual monoenergetic (monoE) images reconstructed from dual energy CT acquisitions potentially decrease artifacts caused by coronary stents. A novel spectral detector technology provides monoE and conventional images simultaneously for all conducted scans. The purpose of our study was to systematically investigate the influence of different monoE reconstructions on the visualization of coronary stent lumen in comparison to conventional images.Ten different coronary stents (diameter 3.0 mm) embedded in plastic tubes filled with contrast agent (500 HU) were scanned with a 128-row spectral detector CT (IQon, Philips, 120 kV, 125 mAs). Images were reconstructed (0.67 mm slice thickness, 0.35 mm increment) with a stent-specific conventional reconstruction kernel and 6 different monoE settings (60, 70, 80, 90, 100, 150 keV). Image quality for each stent and reconstruction was quantified using established parameters: image noise (standard deviation (SD) within a standardized ROI), in-stent attenuation difference (mean attenuation difference between stented and non-stented lumen) and visible lumen diameter (mean visible diameter of the stented tube).Image noise was significantly lower in all monoE data dets compared to conventional images (conventional: 13.41, 60 keV: 11.62, 70 keV: 11.67, 80 keV: 11.69, 90 keV: 11.71, 100 keV: 11.75, 150 keV: 11.80 HU SD; p 0.01). The in-stent attenuation difference was significantly smaller in monoE data with higher keV levels than in conventional images (conventional: 148.18, 60 keV: 154.13 p = 0.036, 70 keV: 143.43 p = 0.109, 80 keV: 137.25 p = 0.052, 90 keV: 133.02 p = 0.043, 100 keV: 130.12 p = 0.039, 150 keV: 123.99 HU p = 0.035). The visible lumen diameter was significantly greater in monoE data with higher keV levels than in conventional images (conventional: 0.65, 60 keV: 0.68 p = 0.542, 70 keV: 0.71 p = 0.053, 80 keV: 0.74 p 0.01, 90 keV: 0.77 p 0.01, 100 keV: 0.82 p 0.01, 150 keV: 0.87 mm p 0.01).In comparison to conventional CT images, well-established parameters for objective assessment of CT image quality for coronary stents are significantly improved by utilization of monoE reconstructions with adequate keV levels derived from data acquired on a novel spectral detector CT platform.

The 2015 European Guidelines on Pulmonary Hypertension did not cover only pulmonary arterial hypertension (PAH), but also other significant subgroups of pulmonary hypertension (PH). In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany to discuss open and controversial issues surrounding the practical implementation of the European Guidelines. Several working groups were initiated, one of which was dedicated to the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). In every patient with PH of unknown cause CTEPH should be excluded. The primary treatment option is surgical pulmonary endarterectomy (PEA) in a specialized multidisciplinary CTEPH center. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. For balloon pulmonary angioplasty (BPA), there is currently only limited experience. This option - as PEA - is reserved to specialized centers with expertise for this treatment method. In addition, a brief overview is given on pulmonary artery sarcoma, since its surgical treatment is often analogous to PEA. The recommendations of this working group are summarized in the present paper.

Myocarditis is known as the chameleon of cardiac diseases. The symptoms and the course of disease vary greatly so that it is often challenging to establish a diagnosis. Early and accurate diagnosis is of utmost importance, since myocarditis is one of the leading causes of sudden cardiac death in young adults and represents an important precursor to dilated cardiomyopathy. Due to the constraints of the routinely used diagnostic approach, including clinical history and examination, laboratory testing, and electrocardiogram, different imaging modalities have emerged over the last decades as contributors to the noninvasive diagnosis of myocarditis. With this interdisciplinary review we would like to present the current state-of-the-art imaging of myocarditis across all available imaging modalities (i. e., echocardiography, cardiac magnetic resonance, cardiac computed tomography, and nuclear medicine). Furthermore, we present novel imaging techniques that might become useful in the near future for easier and more accurate diagnosis of this highly relevant disease.• Different imaging modalities are increasingly used in the diagnostic workup of myocarditis. • Several emerging imaging techniques are currently on the way to becoming part of the clinical routine. • This review summarizes the diagnostic value of echocardiography, CMR, CT, and nuclear medicine imaging. • There is special focus on the possibilities and challenges of novel imaging tools within the different modalities.Die Myokarditis ist bekannt als das Chamäleon unter den kardiologischen Erkrankungen: ihre Symptomatik ebenso wie ihr klinischer Verlauf variieren stark, was die Diagnosestellung zu einer großen Herausforderung macht. Eine frühzeitige und korrekte Diagnosestellung ist jedoch von großer Bedeutung, da die Myokarditis eine der Hauptursachen für den plötzlichen Herztod bei jungen Erwachsenen darstellt und nicht selten in einer dilatativen Kardiomyopathie mündet. Aufgrund der Limitationen der routinemäßig eingesetzten diagnostischen Verfahren (bestehend aus Anamnese, klinischer Untersuchung, Blutuntersuchungen und Elektrokardiogramm) sind unterschiedliche bildgebende Verfahren in den letzten Jahrzehnten unverzichtbar für die nicht-invasive Diagnostik der Myokarditis geworden. Ziel der vorliegenden Übersichtsarbeit ist es deshalb, den derzeitigen Stand der Technik in der Diagnostik der Myokarditis über sämtliche bildgebende Modalitäten (Echokardiografie, kardiale Magnetresonanztomografie, kardiale Computertomografie, nuklearmedizinische Untersuchungstechniken) zusammenzufassen und anschließend einen Einblick in junge, noch nicht vollständig klinisch etablierte Techniken zu geben, welche sich in der näheren Zukunft als nützlich im Hinblick auf eine einfachere und genauere Diagnose dieser relevanten Erkrankung erweisen könnten.

Background The incidence of intracardiac masses is generally low. In most cases, the formation of a thrombus represents the principal diagnosis in clinical practice. The differential diagnosis mainly includes primary tumours of the heart as well as intracardiac metastases. Testicular cancer is a rare malignancy, accounting for approximately 1% of all male tumours. Cardiac metastasis of a seminoma is extremely rare. Case summary A 30-year-old man with a history of a classic seminoma of the right testis was referred to our university hospital from an outside clinic. Transthoracic echocardiography showed a large space-occupying mass in the right ventricle (4.0 cm × 4.5 cm × 5.5 cm) attached to the apex and septum. Cardiac magnetic resonance imaging confirmed the finding of a 5.5 cm × 3.5 cm lesion without freely movable appendage or obstruction of the right ventricular outflow tract. Tissue characterization by T1- and T2-weighted black blood imaging revealed a signal behaviour comparable to pulmonary metastases. Additionally, positron emission tomography (PET) with 250 MBq induced 18-fluorodeoxyglucose (18F-FDG) as part of a re-staging showed significant FDG-uptake. Thus, the final diagnosis of an intracardiac metastasis of the testicular seminoma was made, and the patient was treated with cisplatin, etoposide, and bleomycin chemotherapy according to the current guidelines. A repeat trans-thoracic echocardiogram (TTE) performed 2 weeks later already demonstrated a significant reduction of the metastasis with a diameter of 3.3 cm × 3.0 cm. Discussion In the past few years, multimodality imaging has become essential in the diagnostic evaluation of cardiac disease. In order to improve the diagnostic accuracy, a modern approach should preferably contain the integration of different imaging modalities. Cardiac magnetic resonance imaging as well as 18F-FDG-PET/computed tomography helped us reach the aetiological diagnosis of an intracardiac metastasis and to initiate prompt treatment.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.

Purpose: To compare the radiation doses and image qualities of computed tomography (CT)-guided interventions using a standard-dose CT (SDCT) protocol with filtered back projection and a low-dose CT (LDCT) protocol with both filtered back projection and iterative reconstruction. Materials and Methods: Image quality and radiation doses (dose-length product and CT dose index) were retrospectively reviewed for 130 patients who underwent CT-guided lung interventions. SDCT at 120 kVp and automatic mA modulation and LDCT at 100 kVp and a fixed exposure were each performed for 65 patients. Image quality was objectively evaluated as the contrast-to-noise ratio and subjectively by two radiologists for noise impression, sharpness, artifacts and diagnostic acceptability on a four-point scale. Results: The groups did not significantly differ in terms of diagnostic acceptability and complication rate. LDCT yielded a median 68.6 % reduction in the radiation dose relative to SDCT. In the LDCT group, iterative reconstruction was superior to filtered back projection in terms of noise reduction and subjective image quality. The groups did not differ in terms of beam hardening artifacts. Conclusion: LDCT was feasible for all procedures and yielded a more than two-thirds reduction in radiation exposure while maintaining overall diagnostic acceptability, safety and precision. The iterative reconstruction algorithm is preferable according to the objective and subjective image quality analyses. Key Points: • Implementation of a low-dose computed tomography (LDCT) protocol for lung interventions is feasible and safe. • LDCT protocols yield a significant reduction (more than 2/3) in radiation exposure. • Iterative reconstruction algorithms considerably improve the image quality in LDCT protocols. Citation Format: • Chang DH, Hiss S, Mueller D et al. Radiation Dose Reduction in Computed Tomography-Guided Lung Interventions using an Iterative Reconstruction Technique. Fortschr Rontgenstr 2015; 187: 906 – 914

Background Assesment of the coronary arteries after stent placement using coronary computed tomography angiography (CCTA) currently requires reconstruction of images with soft kernels for the assessment of atherosclerotic plaques and dedicated edge enhancing kernels for the evaluation of the stent lumen. Purpose To evaluate a two-dimensional filter tool that provides instant postprocessing of images reconstructed with soft kernels into edge-enhanced images and vice versa and thus may eliminate the need for two separate reconstrcutions for the assessment of coronary artery stents using CCTA. Material and Methods Twenty stents with a diameter of 3.0 mm placed in a vascular phantom were scanned with a dual-source CT using standard parameters. Images were reconstructed with a soft B30f and an edge-enhancing B46f kernel and postprocessed with the corresponding filter algorithm (F30 for B30f images; F46 for B46f images). The resulting four data-sets were evaluated for lumen visibility, intraluminal attenuation, and image noise by two independent readers. Results were validated in vivo against invasive coronary angiography in data-sets from patients with coronary artery stents. Results Average intraluminal attenuation was 552.6 HU, 527.3 HU, 207.9 HU, and 267.5 HU for B30f, F30, B46f, and F46 images, respectively ( P Conclusion The postprocessing filter reduces image noise, however currently it does not offer an alternative to image reconstruction using the edge-enhancing kernels for the evaluation of the stent lumen.

The availability of insulins with concentrations greater than the standard 100 units/mL (U-100) concentration (adopted in the United States in 1973) provides additional options for managing diabetes, but these agents may be a source of confusion for many clinicians. Our awareness of such confusion has come about after a number of inquiries from health care providers (HCPs) to Lilly Diabetes, U.S. Medical Affairs, and inaccuracies in recent articles and published guidance. The purpose of this editorial is to bring attention to some of the more common and crucial issues and provide relevant background and clinical evidence to address and clarify misunderstandings and instruct HCPs on the safe and appropriate use of these agents. Four concentrated insulins are available in the United States. Three are analog insulins, which have been approved in the past 2–3 years: insulin glargine 300 units/mL (IGlar300) (1), insulin degludec 200 units/mL (IDeg200) (2), and insulin lispro 200 units/mL (ILis200) (3). The fourth, human regular insulin 500 units/mL (U-500R) (4), has been commercially available since 1997. These agents have diverse pharmacokinetic/pharmacodynamic (PK/PD) profiles and were developed to address different challenges of insulin therapy (5). Designing a basal insulin with stable, prolonged action was the rationale for IGlar300 (6). Insulin degludec was also developed as a longer-acting basal agent; the concentrated formulation (IDeg200) may benefit patients with higher insulin requirements (7). The more stable and protracted time-action profile for IGlar300 and insulin degludec (both 100 and 200 units/mL) supports once-daily dosing and may result in reduced hypoglycemia compared to insulin glargine 100 units/mL (IGlar100) (6–18). Rapid-acting prandial ILis200 is delivered in half the volume of the corresponding U-100 formulation, allowing a twofold increase in device capacity (19) and resulting in a longer-lasting pen. U-500R is a prandial/basal agent intended specifically for patients with severe insulin resistance …

The incidence of blunt chest trauma (BCT) is greater than 15% of all trauma admissions to the emergency departments worldwide and is the second leading cause of death after head injury in motor vehicle accidents. The mortality due to BCT is inhomogeneously described ranging from 9% to 60%. BCT is commonly caused by a sudden high-speed deceleration trauma to the anterior chest, leading to a compression of the thorax. All thoracic structures might be injured as a result of the trauma. Complex cardiac arrhythmia, heart murmurs, hypotension, angina-like chest pain, respiratory insufficiency or distention of the jugular veins may indicate potential cardiac injury. However, on admission to emergency departments symptoms might be missing or may not be clearly associated with the injury. Accurate diagnostics and early management in order to prevent serious complications and death are essential for patients suffering a BCT. Optimal initial diagnostics includes echocardiography or CT, Holter-monitor recordings, serial 12-lead electrocardiography and measurements of cardiac enzymes. Immediate diagnostics leading to the appropriate therapy is essential for saving a patient’s life. The key aspect of the entire management, including diagnostics and treatment of patients with BCT, remains an interdisciplinary team involving cardiologists, cardiothoracic surgeons, imaging radiologists and trauma specialists working in tandem.

The objective of the current work was to evaluate flow and turbulent kinetic energy in different transcatheter aortic valve implants using highly undersampled time-resolved multi-point 3-directional phase-contrast measurements (4D Flow MRI) in an in vitro setup. A pulsatile flow setup was used with a compliant tubing mimicking a stiff left ventricular outflow tract and ascending aorta. Five different implants were measured using a highly undersampled multi-point 4D Flow MRI sequence. Velocities and turbulent kinetic energy values were analysed and compared. Strong variations of turbulent kinetic energy distributions between the valves were observed. Maximum turbulent kinetic energy values ranged from 100 to over 500 J/m3 while through-plane velocities were similar between all valves. Highly accelerated 4D Flow MRI for the measurement of velocities and turbulent kinetic energy values allowed for the assessment of hemodynamic parameters in five different implant models. The presented setup, measurement protocol and analysis methods provides an efficient approach to compare different valve implants and could aid future novel valve designs.

Background: Left ventricular longitudinal strain (LV-LS) and strain rate (SR) are sensitive markers of early systolic dysfunction. Aim: To evaluate the feasibility of a novel, cardiac magnetic resonance (CMR) based method known as feature tracking (FT) for the assessment of strain and SR, and to compare the CMR based results to those obtained on standard transthoracic echocardiography (TTE) in healthy volunteers and in patients with left ventricular hypertrophy cardiomyopathy (HCM). Methods: Overall, 20 healthy volunteers (ten male, mean age 24 ± 3 years) and 20 consecutive patients with HCM (12 male, mean age 47 ± 19 years) were included. Longitudinal and circumferential strain and SR of the left ventricle were measured on CMR at 1.5 Tesla and TTE and interobserver variability was assessed. Results: FT measurements were feasible in all subjects. A good agreement between global LV-LS measured on CMR (controls: 20.8 ± 3.0; HCM: 17.6 ± 3.8) and TTE (controls: 19.4 ± 2.1; HCM: 16.6 ± 2.9) was found, while the agreement was worse for circumferential strain and all SR measurements. For the left and right ventricles, interobserver reproducibility was higher for strain measurements compared to SR. Coefficients of variation were lowest for LV-LS (13.2%) by CMR. Conclusions: FT analysis is a novel CMR based method for the analysis of myocardial strain and SR that is simple and correlates well with the echocardiographic measurements. Since CMR is unaffected by inadequate acoustic windows, FT may represent an attractive alternative to echocardiography in assessing the increasingly important parameters of myocardial deformation.

Despite continuous improvements in CT technology, accurate stent lumen delineation remains challenging.The aim was to evaluate the quality of coronary stent lumen delineation with CT using a detector with integrated electronics.Twelve coronary stents placed in plastic tubes and filled with contrast agent (CT number 250 HU) were imaged with either a 128-section dual-source CT machine equipped with conventional detector or with integrated electronics. On both scanners, images were reconstructed with filtered back projection (slice thickness 0.6 mm; increment 0.4 mm) and sinogram-affirmed iterative reconstruction (slice thickness 0.6 mm; increment 0.4 mm), and with iterative reconstruction (slice thickness 0.5 mm; increment 0.3 mm) on the integrated scanner. Two blinded, independent readers assessed image quality, noise, in-stent diameter, in-stent attenuation, and image sharpness by using signal intensity profiles across stents.Interreader agreement for image quality assessment was substantial (κ = 0.798). Both readers rated best image quality in data sets from integrated detector at highest spatial resolution (86 or 72% of stents rated best quality). Image noise was significantly lower in data sets scanned with integrated detector, being lowest at 0.6 mm slice thickness (14.3 vs 21.0 HU; P.001). Differences between measured and true in-stent diameters and differences in attenuation across stents were smallest, and average/maximum image sharpness was highest in data sets from the integrated detector using iterative reconstructions.CT coronary stent imaging is significantly improved by using a detector with integrated electronics combined with iterative reconstructions.

Purpose: To analyze the underlying causes of anxiety in patients undergoing coronary computed tomography angiography (CCTA) and to correlate anxiety to patient-related factors (e.g. anxiety concerning the potential diagnosis of CAD or claustrophobia), in order to establish a patient-related risk profile for anxiety. Methods: We conducted a single-center cross-sectional analysis of patients’ anxiety and the underlying causes of anxiety prior to a CCTA-scan, including 325 patients. Questions concerning the patients’ state of anxiety and the underlying causes were asked by the radiologist during the standard informed consent prior to the CCTA-examination. Statistical analysis was performed including patient-related factors. Results: In total, 47.3% of patients reported a feeling of anxiety before undergoing CCTA (n=146). Anxiety showed much higher prevalence in women than in men (60.0% vs. 39.1%, p

Purpose The present study aims at evaluating the feasibility and reproducibility of cardiac magnetic resonance (CMR) feature tracking (FT) derived strain and strain rate (SR) parameters of the left and right atrium (LA, RA) in patients with acute myocarditis as well as their potential to detect diastolic dysfunction. In addition, the diagnostic value of LA and RA strain parameters in the setting of acute myocarditis is investigated. Methods CMR cine data of 30 patients with CMR-positive acute myocarditis were retrospectively analyzed. 25 age- and gender-matched healthy individuals served as a control. Analysis of longitudinal strain and SR of both atria was performed in two long-axis views using a dedicated FT-software. LA and RA deformation was analyzed including reservoir function (total strain [e s ], peak positive SR [SR s ]), conduit function (passive strain [e e ], peak early negative SR [SR e ]) and booster pump function (active strain [e a ], peak late negative SR [SR a ]). Intra- and inter-observer reproducibility was assessed for all strain and SR parameters using Bland-Altman analyses, intra-class correlation coefficients (ICCs) and coefficients of variation (CV). Results FT analyses of both atria were feasible in all patients and controls. Reproducibility was good for reservoir and conduit function parameters and moderate for booster pump function parameters. Myocarditis patients demonstrated an impaired LA reservoir and conduit function when compared to healthy controls (LA e s : 32±17 vs. 46±13, p=0.019; LA SR s : 1.5±0.5 vs. 1.8±0.5, p=0.117; LA SR e : −1.3±0.5 vs. −1.9±0.5, p e proved to be the best independent predictor of acute myocarditis (AUC 0.80), and using LA SR e with a cut-off of −1.6s −1 resulted in a diagnostic sensitivity of 83% and a specificity of 80%. Changes in RA phasic function parameters showed a tendency to parallel those of the LA and showed no additional effect with respect to the diagnostic potential in acute myocarditis. Conclusions Myocarditis patients exhibit an impaired atrial reservoir and conduit function, what might be indicative of ventricular diastolic dysfunction. LA SR e was the best predictor for the presence of acute myocarditis in our study, pointing towards the discriminative power of atrial strain analysis in the CMR-based diagnosis of acute myocarditis.

Background: Bone metabolism is a dynamic process that is influenced by food ingestion. Endogenous incretins have been shown to be important regulators of bone turnover. The aim of the present study was to assess whether a dipeptidylpeptidase (DPP)-4 inhibitor affects markers of bone resorption and calcium homeostasis. Methods: The present study was a single-center, double blind, randomized clinical trail. Fifty-nine drug-naive patients with type 2 diabetes (T2D) were randomized to either 1year treatment with the DPP-4 inhibitor vildagliptin (100mg, once daily; n=29) or placebo (n=30). Patients received a standardized breakfast after measurement of serum concentrations of cross-linked C-terminal telopeptide (s-CTx), a bone resorption marker influenced by food intake, before and after 50weeks treatment. Results: Vildagliptin did not change postprandial s-CTx concentrations compared with pretreatment levels (between-group ratio 1.15±0.17; P=0.320). Fasting serum alkaline phosphatase, calcium, and phosphate were also unaffected y 1year treatment with vildagliptin. Conclusions: Treatment with vildagliptin for 1year was not associated with changes in markers of bone resorption and calcium homeostasis in drug-naive patients with T2D and mild hyperglycemia. © 2011 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd.

To analyse cerebrospinal fluid (CSF) hydrodynamics in patients with Chiari type I malformation (CM) with and without syringomyelia using 4D magnetic resonance (MR) phase contrast (PC) flow imaging. 4D-PC CSF flow data were acquired in 20 patients with CM (12 patients with presyrinx/syrinx). Characteristic 4D-CSF flow patterns were identified. Quantitative CSF flow parameters were assessed at the craniocervical junction and the cervical spinal canal and compared with healthy volunteers and between patients with and without syringomyelia. Compared with healthy volunteers, 17 CM patients showed flow abnormalities at the craniocervical junction in the form of heterogeneous flow (n = 3), anterolateral flow jets (n = 14) and flow vortex formation (n = 5), most prevalent in patients with syringomyelia. Peak flow velocities at the craniocervical junction were significantly increased in patients (−15.5 ± 11.3 vs. −4.7 ± 0.7 cm/s in healthy volunteers, P

Objectives To assess ventricular dysfunction and ventricular interaction after repair of Tetralogy of Fallot (ToF) employing echocardiography speckle-tracking and cardiac magnetic resonance imaging (CMR). Background Severe pulmonary regurgitation and right ventricular (RV) dysfunction are common after repair of ToF and may also affect the shape and function of the left ventricle (LV). Recent studies suggest that LV dysfunction may be of particular prognostic value. Methods and results Twenty-one consecutive adults with repaired ToF (15 male, mean age 38±11years, 7 with severe PR) underwent a comprehensive echocardiographic exam including speckle-tracking analysis, CMR and cardiopulmonary exercise testing. Twenty-one subjects without relevant heart disease served as controls. Echocardiographically measured RV diameters correlated with RV volumes obtained from CMR ( r =0.63; p =0.006). In addition, a close correlation was found between RV and LV function on CMR ( r =0.74, p =0.002), speckle-tracking LV and RV peak longitudinal 2D strain ( r =0.66, p =0.003) and mitral and tricuspid annular plain systolic excursion ( r =0.71, p =0.0003). While LV ejection fraction was normal in the majority of patients and not different from controls, LV longitudinal strain was significantly reduced in ToF patients (−16.5±3.3 vs. -20.5±2.7%, p =0.0001). Conclusion Left and right ventricular function both by CMR and speckle-tracking is interrelated in adults with repaired ToF. Despite normal LV ejection fraction, 2D longitudinal strain is significantly reduced in ToF patients, suggesting subclinical LV myocardial damage. Considering the potential prognostic value of LV dysfunction in ToF, this measurement may gain importance and should be included in future outcome studies.

Takotsubo cardiomyopathy (TTC) usually occurs in postmenopausal women after acute physical or mental stress and typically presents with apical ballooning of the left ventricle. TTC manifests with symptoms similar to acute coronary syndrome and may be accompanied by ECG changes, so coronary angiography is mandatory to exclude acute coronary syndrome. Other forms of TTC with atypical mid-ventricular ballooning have been described. Severe cerebral damage may also go along with ECG changes such as ST segment elevation, release of cardiac enzymes and/or cardiac dysfunction and often presents similar to TTC. For that reason a recent review postulates a pathophysiological relationship between TTC and cardiac dysfunction after cerebral bleeding.

Rationale and Objectives To prospectively compare the diagnostic performance of two-dimensional (2D) and high spatial resolution three-dimensional (3D) late enhancement magnetic resonance imaging (MRI) for the detection of scar tissue caused by catheter ablation of the right atrium in patients with atrial flutter. Materials and Methods Forty-seven patients were enrolled. In 16 patients, imaging of the cavotricuspid isthmus was performed before and after catheter ablation, 16 subjects were imaged before, and 15 after catheter ablation, resulting in a total of 63 examinations. MRI included a standard 2D breathhold and a high-resolution navigator-gated 3D T1-weighted gradient-echo inversion-recovery sequence in right and left anterior oblique views. Two readers assessed the subjective image quality on a 4-point scale (1 = excellent) and the presence of late enhancement (blinded/ in consensus). Results The average image quality was 1.6 for both imaging approaches. In consensus reading, the sensitivity was 83% versus 100%, specificity 97% versus 89%, accuracy 90% versus 94%, positive predictive value 96% versus 89%, negative predictive value 86% versus 100% for 2D and 3D, respectively. The interobserver agreement was 0.86 for 2D and 0.78 for 3D imaging. Conclusions For the noninvasive identification of scars in the cavotricuspid isthmus after right atrial flutter, ablation 2D imaging was more consistent, whereas 3D sequences showed superior sensitivity for the depiction of late enhancement.

To evaluate the applicability of 4D phase contrast (4D PC) MR imaging in the assessment of cerebrospinal fluid dynamics in healthy volunteers and patients with lesions at the craniocervical junction or the cervical spinal canal.Ten healthy volunteers and four patients with lesions including Chiari I malformation and cervical canal stenoses were examined by a cardiac-gated 4D PC imaging sequence on 1.5T MRI. Phase contrast images were postprocessed allowing for flow quantification and flow pathline visualisation. Velocity data were compared with conventional axial 2D phase contrast images.The 4D PC sequence allowed for flow quantification and visualisation in all individuals. Bland-Altman analysis showed good agreement of 2D and 4D PC velocity data. In healthy volunteers, CSF flow was homogeneously distributed in the anterior and anterolateral subarachnoid space with the flow directed caudally during systole and cranially during diastole. Flow velocities were closely related to the width of the subarachnoid space. Patients showed grossly altered CSF flow patterns with formation of flow jets with increased flow velocities.4D PC MR imaging allows for a detailed assessment of CSF flow dynamics helping to distinguish physiological from complex pathological flow patterns at the craniocervical junction and the cervical spine.

Aims/hypothesis Traditional blood glucose lowering agents do not prevent the progressive loss of beta cell function in patients with type 2 diabetes. The dipeptidylpeptidase (DPP)-4 inhibitor vildagliptin improves beta cell function both acutely and chronically (up to 2 years). Whether this effect persists after cessation of treatment remains unknown. Here, we assessed the insulin secretory capacity in drug-naive patients with type 2 diabetes after a 52 week treatment period with vildagliptin or placebo, and again after a 12 week washout period. Methods This study was conducted at a single university medical centre, and was a double-blind, randomised clinical trial in 59 drug-naive patients with type 2 diabetes and mild hyperglycaemia to either vildagliptin 100 mg (n = 29) or placebo (n = 30). Randomisation was performed by a validated 1:1 system. Neither patient, nor caregiver, was informed about the assigned treatment. Inclusion criteria were drug-naive patients ≥30 years, with HbA1c ≤7.5% and BMI of 22–45 kg/m2. The mildly hyperglycaemic patient population was chosen to minimise glucose toxicity as a confounding variable. Beta-cell function was measured during an arginine-stimulated hyperglycaemic clamp at week 0, week 52 and after a 12 week washout period. All patients with at least one post-randomisation measure were analysed (intent-to-treat). Results Fifty-two week vildagliptin 100 mg (n = 26) treatment increased the primary efficacy variable, combined hyperglycaemia and arginine-stimulated C-peptide secretion (AIRarg), by 5.0 ± 1.8 nmol/l × min, while it decreased by 0.8 ± 1.8 nmol/l × min with placebo (n = 25) (between-group difference p = 0.030). No significant between-group difference in AIRarg was seen after the 12 week washout period. The between-group difference adjusted mean 52 week changes from baseline was −0.19 ± 0.11, p = 0.098 and −0.22 ± 0.23%, p = 0.343 for HbA1c and fasting plasma glucose, respectively. There were no suspected drug treatment-related serious adverse events. Conclusions/interpretation One year treatment with vildagliptin significantly increased beta cell secretory capacity. This effect was not maintained after the washout, indicating that this increased capacity was not a disease modifying effect on beta cell mass and/or function. Trial registration: ClinicalTrials.gov NCT00260156 Funding: This study was sponsored by the Novartis Pharmaceutical Cooperation.

RATIONALE AND OBJECTIVES: To evaluate the quality of stent lumen delineation using dual-source computed tomography (DSCT) in the standard-pitch mode (SP) as compared to the high-pitch mode (HP) in a phantom study. MATERIALS AND METHODS: Forty different coronary stents placed in plastic tubes filled with contrast agent were imaged with a second generation DSCT system in a SP (pitch 0.23) and HP (pitch 3.4) mode in orientations of 0°, 45°, and 90° relative to the z-axis. Two observers independently measured the in-stent lumen and the attenuation values in the center of the stents. The artificial lumen narrowing (ALN) was calculated using the measured in-stent lumen and the nominal diameter of the plastic tube. RESULTS: Interobserver correlation was excellent for in-stent lumen (0.86) and attenuation measurements (0.91). There was no significant difference neither for ALN (SP: 54.7-62.8%; HP: 55.8-64.0%) nor attenuation (SP: 356-395 Hounsfield units [HU]; HP: 352-384 HU) between SP and HP mode. For both modes, the orientation of the stent relative to the z-axis significantly affected ALN and attenuation (each P < .001). CT volume dose index was significantly lower using HP mode as compared to SP mode (P < .001). CONCLUSION: The HP mode in DSCT provides visualization of the coronary in-stent lumen comparable to that measured in SP mode while reducing applied radiation dose in a stationary phantom model.

Hyperintense areas in atherosclerotic plaques on pre-contrast T1-weighted MRI have been shown to correlate with intraplaque haemorrhage. We evaluated the presence of T1 hyperintensity in coronary artery plaques in coronary artery disease (CAD) patients and correlated results with multi-detector computed tomography (MDCT) findings. Fifteen patients with CAD were included. Plaques detected by MDCT were categorised based on their Hounsfield number. T1-weighted inversion recovery (IR) MRI prepared coronary MRI for the detection of plaque and steady-state free-precession coronary MR-angiography for anatomical correlation was performed. After registration of MDCT and MRI, regions of interest were defined on MDCT-visible plaques and in corresponding vessel segments acquired with MRI. MDCT density and MR signal measurement were performed in each plaque. Forty-three plaques were identified with MDCT. With IR-MRI 5/43 (12%) plaques were hyperintense, 2 of which were non-calcified and 3 mixed. Average signal-to-noise and contrast-to-noise ratios of hyperintense plaques were 15.7 and 9.1, compared with 5.6 and 1.2 for hypointense plaques. Hyperintense plaques exhibited a significantly lower CT density than hypointense plaques (63.6 vs. 140.8). There was no correlation of plaque signal intensity with degree of stenosis. T1-weighted IR-MRI may be useful for non-invasive detection and characterisation of intraplaque haemorrhage in coronary artery plaques.