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La insuficiencia cardíaca (IC) es una de las principales causas de morbimortalidad de nuestro medio, siendo la más importante tras la cardiopatía isquémica y las enfermedades cerebrovasculares. En los últimos años la mortalidad por IC se ha reducido debido a mejoras en el tratamiento con fármacos, como los inhibidores de la enzima convertidora de la angiotensina (IECAS), los β-bloqueantes y los antagonistas de aldosterona (ARB) y tras la introducción de los dispositivos de resincronización cardíaca. Cuando el paciente es refractario a estas medidas, el trasplante cardíaco es el tratamiento de elección. En las últimas décadas se calcula que se realizan entre 3.600 y 3.850 trasplantes cardíacos al año en el mundo. Se estima que la supervivencia de los pacientes trasplantados de corazón es del 85% al año del trasplante, del 80% a los 3 años y del 50% a los 10 años. La supervivencia a corto plazo viene marcada por el rechazo agudo y las infecciones, mientras que las neoplasias y la enfermedad vascular del injerto (EVI) constituyen las enfermedades que limitan la supervivencia del injerto a largo plazo. La EVI es una vasculopatía que afecta exclusivamente al injerto cardíaco y se caracteriza por una hiperplasia difusa y concéntrica de la íntima del vaso, que conlleva un compromiso progresivo de la luz, obliterando las arterias intramurales y epicárdicas. Hoy en día, la coronariografía convencional es el método diagnóstico de elección para descartar la EVI. Sin embargo, al tratarse de una prueba invasiva, se han buscado métodos alternativos no invasivos para el diagnóstico, caracterización y seguimiento de la EVI. En los últimos años la TC cardíaca (TCC) y, en particular, la coronariografía por TC (CTC), se ha convertido en una de las herramientas más útiles para estudiar el corazón trasplantado, ya que permite valorar su anatomía, función y vascularización coronaria con gran precisión. Estudios recientes demuestran que la CTC es una técnica útil para diagnosticar y realizar el control evolutivo de la EVI. Sin embargo, se desconoce el valor pronóstico de la prueba. Este trabajo de tesis se realizó con el fin de valorar la utilidad y el valor pronóstico de la CTC en el seguimiento del paciente trasplantado cardíaco.

Background and objective: The availability of chest computed tomography (CT) imaging can help diagnose comorbidities associated with chronic obstructive pulmonary disease (COPD). Their systematic identification and relationship with allcause mortality have not been explored. Furthermore, whether their CT-detected prevalence differs from clinical diagnosis is unknown. Methods: The prevalence of 10 CT-assessed comorbidities was retrospectively determined at baseline in 379 patients (71% men) with mild to severe COPD attending pulmonary clinics. Anthropometrics, smoking history, dyspnoea, lung function, exercise capacity, BODE (BMI, Obstruction, Dyspnoea and Exercise capacity) index and exacerbations rate were recorded. The prevalence of CT-determined comorbidities was compared with that recorded clinically. Over a median of 78 months of observation, the independent association with all-cause mortality was analysed. A ‘CT-comorbidome’ graphically expressed the strength of their association with mortality risk. Results: Coronary artery calcification, emphysema and bronchiectasis were the most prevalent comorbidities (79.8%, 62.7% and 33.9%, respectively). All were underdiagnosed before CT. Coronary artery calcium (hazard ratio [HR] 2.09; 95% CI 1.03–4.26, p = 0.042), bronchiectasis (HR 2.12; 95% CI 1.05–4.26, p = 0.036) and low psoas muscle density (HR 2.61; 95% CI 1.23–5.57, p = 0.010) were independently associated with all-cause mortality and helped define the ‘CT-comorbidome’. Conclusion: This study of COPD patients shows that systematic detection of 10 CT-diagnosed comorbidities, most of which were not detected clinically, provides information of potential use to patients and clinicians caring for them.

Monitoring renal allograft function after transplantation is key for the early detection of allograft impairment, which in turn can contribute to preventing the loss of the allograft. Multiparametric renal MRI (mpMRI) is a promising noninvasive technique to assess and characterize renal physiopathology; however, few studies have employed mpMRI in renal allografts with stable function (maintained function over a long time period). The purposes of the current study were to evaluate the reproducibility of mpMRI in transplant patients and to characterize normal values of the measured parameters, and to estimate the labeling efficiency of Pseudo-Continuous Arterial Spin Labeling (PCASL) in the infrarenal aorta using numerical simulations considering experimental measurements of aortic blood flow profiles. The subjects were 20 transplant patients with stable kidney function, maintained over 1 year. The MRI protocol consisted of PCASL, intravoxel incoherent motion, and T1 inversion recovery. Phase contrast was used to measure aortic blood flow. Renal blood flow (RBF), diffusion coefficient (D), pseudo-diffusion coefficient (D*), flowing fraction ( f ), and T1 maps were calculated and mean values were measured in the cortex and medulla. The labeling efficiency of PCASL was estimated from simulation of Bloch equations. Reproducibility was assessed with the within-subject coefficient of variation, intraclass correlation coefficient, and Bland-Altman analysis. Correlations were evaluated using the Pearson correlation coefficient. The significance level was p less than 0.05. Cortical reproducibility was very good for T1, D, and RBF, moderate for f , and low for D*, while medullary reproducibility was good for T1 and D. Significant correlations in the cortex between RBF and f (r = 0.66), RBF and eGFR (r = 0.64), and D* and eGFR (r = -0.57) were found. Normal values of the measured parameters employing the mpMRI protocol in kidney transplant patients with stable function were characterized and the results showed good reproducibility of the techniques.

Las arterias coronarias son las encargadas de suministrar constantemente oxígeno y nutrientes al corazón. Su estrechamiento u obstrucción causan isquemia y, si no se tratan, provocan la enfermedad isquémica del corazón (CAD), una de las enfermedades cardiovasculares con mayor tasa de mortalidad en Estados Unidos y Europa. La cuantificación de la perfusión miocárdica es un factor clave para el diagnóstico y evaluación de CAD. La perfusión miocárdica se evalúa en resonancia magnética con una técnica de imagen llamada first-pass que requiere de la inyección de un material de contraste basado en Gadolinio, el cual limita la repetibilidad de la técnica y restringe su uso en pacientes con una función renal anormal. Arterial Spin Labeling (ASL) es una técnica de imagen por resonancia magnética que permite cuantificar la perfusión sin necesidad de inyectar un agente de contraste, a través del marcado electromagnético del agua contenida en la sangre arterial, actuando como trazador endógeno. El principal inconveniente de esta técnica es que la magnitud de este trazador es pequeña, debido a la reducida cantidad de sangre marcada por volumen de tejido, y decae con el tiempo de relajación T1. Por tanto, la relación señal/ruido es relativamente baja. Además, su aplicación en el corazón es complicada debido al continuo movimiento y al tortuoso camino que realiza la sangre arterial a través del corazón, lo cual dificulta un marcado preciso. En esta tesis, la técnica ASL (adquisición y procesado de datos) fue optimizada para su utilización en voluntarios sanos y pacientes. En particular, la técnica ASL fue implementada, optimizada y validada en el corazón de sujetos sanos bajo condiciones de reposo y estrés leve mediante el levantamiento pasivo de piernas. Distintas estrategias fueron evaluadas para minimizar el movimiento cardíaco y respiratorio durante la adquisición y el post-procesado de las imágenes de perfusión. Finalmente, la aplicación de la secuencia ASL en el corazón fue evaluada en un grupo de pacientes con sospecha de CAD en condiciones de reposo y vasodilatación farmacológica. La validación de la secuencia miocárdica ASL en voluntarios sanos mostró una mayor eficiencia en el tiempo de adquisición con la utilización de un TR corto de aproximadamente cuatro segundos, el cual proporcionó medidas de reproducibilidad razonables (coeficientes de variación entre sujeto de 17% intrasesión y 37% intersesión). La comparación entre las distintas estrategias de respiración y técnicas de corrección de movimiento mostró la superioridad de la respiración libre en combinación con el método de registro pairwise , resultando en una mayor precisión tras el registro de imágenes sintéticas y mejores resultados de reproducibilidad intrasesión (coeficientes de variación entre sujeto de 14%) junto con una menor variabilidad entre sujetos en la perfusión tras el registro de imágenes reales. Las estrategias de apnea y respiración sincronizada combinadas con el algoritmo de detección de movimiento mostraron resultados similares, pero su aplicación práctica requiere colaboración, lo cual puede ser problemático en pacientes con sospecha de CAD. El estudio clínico ASL demostró la capacidad de la técnica ASL para detectar hiperemia debida a la vasodilatación, para identificar diferencias significativas en la reserva de perfusión miocárdica (MPR) entre segmentos normales e hipoperfundidos y correlaciones de MPR entre ASL y first-pass semicuantitativo, lo que en conjunto sugieren el potencial clínico de la técnica ASL para detectar defectos de perfusión sin el uso de un contraste exógeno.

The prevalence of nonalcoholic fatty liver disease (NAFLD) has dramatically increased in the 2–3 last decades and it represents the most frequent global cause of liver disease, affecting 25% to 45% of adults in most studies (1). The worldwide elevation in the population rates of NAFLD has come in parallel with rising unprecedented pandemics of obesity and diabetes. There is no specific medication for NAFLD and dietary/lifestyle modifications are the main foundations for the treatment of NAFLD. They are also very likely to be effective for its primary prevention. In this context, a dietary pattern that meets most requirements to become the ideal model for the prevention of NAFLD is the traditional Mediterranean diet (2). In addition to the potential for preventing NAFLD, the Mediterranean diet has sufficiently demonstrated its great ability to improve cardiovascular health. The accrual of prospective and well conducted studies showing cardiovascular benefits associated with better adherence to a high-quality food pattern is superior for the traditional Mediterranean food pattern than for any other dietary pattern (3).

Objetivo: El objetivo principal de este estudio es evaluar los resultados y beneficios de la simpaticólisis percutánea con TC mediante radiofrecuencia (RF) en pacientes con hiperhidrosis palmar primaria en términos de seguridad, satisfacción del paciente y eficacia a corto y a largo plazo. Material y métodos: Se analizaron retrospectivamente un total de 136 procedimientos realizados entre mayo de 2010 y septiembre de 2015 en 108 pacientes (edad media 29,9 ± 10,9 años), incluidos 50 hombres y 58 mujeres, con hiperhidrosis palmar primaria y resistencia terapéutica a tratamientos no quirúrgicos y que rechazaban la cirugía convencional. El tratamiento de simpaticolisis percutánea se realizó de forma bilateral bajo guía de fluro-TC en los niveles T2, T3 y T4 empleando ablación térmica con RF alcanzando una temperatura de 90ºC durante 8 minutos. Los procedimientos se realizaron siempre con la colaboración de un anestesista, bajo medidas de asepsia, a través de una buena planificación para la selección del acceso adecuado, empleando las medidas necesarias para disminuir la dosis de radiación y los criterios de seguridad básicos en procedimientos intervencionistas. En primer lugar, se analizaron el éxito técnico, la eficacia inmediata, los parámetros relacionados con la dosis de radiación y la presencia de complicaciones inmediatas relacionadas con el procedimiento. Posteriormente, para el seguimiento a largo plazo, se utilizó una escala específica de gravedad de la hiperhidrosis (HDSS) para evaluar la severidad de la hiperhidrosis antes, al mes, y en el seguimiento a largo plazo a través de una encuesta, a la que respondieron un total de 42 pacientes. También se evaluaron el grado de satisfacción, las complicaciones a largo plazo (como el desarrollo de hiperhidrosis compensatoria) y se analizaron los pacientes re-tratados. Resultados: La tasa de éxito técnico del procedimiento fue 98,5 %. El aumento en la temperatura palmar fue de 4,9°. Un total de 85,3 % de los participantes tenían manos completamente secas inmediatamente después del tratamiento. El tiempo medio de seguimiento fue de 41,3 meses (rango: 6-62 meses). Un mes después del tratamiento, la tasa de respuesta fue del 77,4 % (p

Purpose of review This review article discusses the evolution of extracellular volume (ECV) quantification using both cardiovascular magnetic resonance (CMR) and computed tomography (CT). Recent findings Visualizing diffuse myocardial fibrosis is challenging and until recently, was restricted to the domain of the pathologist. CMR and CT both use extravascular, extracellular contrast agents, permitting ECV measurement. The evidence base around ECV quantification by CMR is growing rapidly and just starting in CT. In conditions with high ECV (amyloid, oedema and fibrosis), this technique is already being used clinically and as a surrogate endpoint. Non-invasive diffuse fibrosis quantification is also generating new biological insights into key cardiac diseases. Summary CMR and CT can estimate ECV and in turn diffuse myocardial fibrosis, obviating the need for invasive endomyocardial biopsy. CT is an attractive alternative to CMR particularly in those individuals with contraindications to the latter. Further studies are needed, particularly in CT.

EAT volume is increased in COPD patients and is independently associated with smoking history, BMI and exercise capacity, all modifiable risk factors of future cardiovascular events. EAT volume could be a non-invasive marker of COPD patients at high risk for future cardiovascular events

We present the case of a 66-year-old woman who underwent orthotopic heart transplantation 17 years earlier for dilated cardiomyopathy. After 7 years allograft coronary vasculopathy developed requiring coronary artery angioplasty. In year 15 postoperatively she experienced congestive heart failure and she became symptomatic requiring diuretics and digoxin treatment. In year 16 postoperatively a routine coronary computed tomography (CT) angiography study revealed a giant thrombus in the left atrium. The patient had had no thromboembolicrelated symptoms. Anticoagulation therapy was introduced and the patient has not presented any thromboembolic-related complication. As the symptoms of cardiac insufficiency worsened we decided to evaluate the patient for re-transplantation.

Electromagnetic navigation bronchoscopy (ENB) has been developed as a novel ancillary tool for the bronchoscopic diagnosis of pulmonary nodules. Despite successful navigation in 90% of patients, ENB diagnostic yield does not generally exceed 70%. We sought to determine whether the presence of a bronchus sign on CT imaging conditions diagnostic yield of ENB and might account for the discrepancy between successful navigation and diagnostic yield. METHODS: We conducted a prospective, single-center study of ENB in 51 consecutive patients with pulmonary nodules. ENB was chosen as the least invasive diagnostic technique in patients with a high surgical risk, suspected metastatic disease, or advanced-stage disease, or in those who demanded a preoperative diagnosis prior to undergoing curative resection. We studied patient and technical variables that might condition diagnostic yield, including size, cause, location, distance to the pleural surface, and fluorodeoxyglucose uptake of a given nodule; the presence of a bronchus sign on CT imaging; registration point divergence; and the minimum distance from the tip of the locatable guide to the nodule measured during the procedure. RESULTS: The diagnostic yield of ENB was 67% (34/51). The sensitivity and specificity of ENB for malignancy in this study were 71% and 100%, respectively. ENB was diagnostic in 79% (30/38) patients with a bronchus sign on CT imaging but only in 4/13 (31%) with no discernible bronchus sign. Univariate analysis identified the bronchus sign (P = .005) and nodule size (P = .04) as statistically significant variables conditioning yield, but on multivariate analysis, only the bronchus sign remained significant (OR, 7.6; 95% CI, 1.8-31.7). No procedure-related complications were observed. CONCLUSIONS: ENB diagnostic yield is highly dependent on the presence of a bronchus sign on CT imaging.

Objetivo: Comparar la exactitud de 2 secuencias cine eco degradiente para cuantificar función, volúmenes y masa ventricular izquierda en un modelo animal. Material y métodos: Se estudiaron 10 cerdos miniatura tipo Goettingen(7 machos,3 hembras; peso medio: 49, 8710, 65 kg; rango: 35–65 kg)en un equipo 1, 5 Tesla con secuencias recesión libre en estado estacionario(SSFP)y ecodegradiente convencionales (FLASH) en respiración libre. Se utilizaron imágenes de 8 mm de grosor obtenidas en el eje corto para cuantificar los parámetros del ventrículo izquierdo. Se calcularon la fracción de eyección (FE), volúmenes (volumen telediastólico [VTD], volumen telesistólico [VTS], volumen latido[VL]), masa ventricular y la relación señal ruido(RSR)con cada secuencia. Se estudiaron la correlación y concordancia entre las distintas secuencias para cada variable.

The shape of the L5 vertebral body was analyzed using a computerized tomography (CT) scan. OBJECTIVE: The aim of this study is to determine if the vertebral L5 body shape varies depending on the height of the CT slices through the L5 pedicle. SUMMARY OF BACKGROUND DATA: The morphometry of L5 has been studied to help the introduction of pedicular screws. The shape of the vertebral body has been seldom looked into, and the findings obtained show a triangular shape and hemispherical shape, supposedly owing to interpersonal variability. The hemisphere shape enables pedicular screws to be introduced nonconvergently, whereas the triangular shape enables pedicular screws to be introduced at a convergent angle but posing the risk of cortical perforation unless these guidelines are followed. METHODS: Abdominal CT multicut with 64 crowns was performed in 101 consecutive patients with diverse indications. Width of CT slices was with a 1-mm reconstruction increase. We selected one axial slice that passed through the upper part of the pedicle and another one that passed through the lower part of the pedicle and compared next parameters in both cuts: pedicular cortical width, pedicular endostal width, pedicular angle, vertebral body length, vertebral body width, vertebral perimeter angles, and visual appearance of vertebral body shape. RESULTS: We found statistical differences between all values except the anterior vertebral perimeter angle on comparing values of upper part with values of lower part and visual vertebral body shape was different in 93% of vertebrae. In the upper part the vertebral body is hemispherical whereas in the lower part it is triangular. CONCLUSION: In most cases, the vertebral body shape is hemispherical in the upper part of the pedicle and triangular in the lower part of the pedicle. It means that in the lower part pedicular screws must be introduced at a more convergent angle than in the upper part if we do not want to break any cortical of the vertebral body.

Identification of risk factors for lung cancer can help in selecting patients who may benefit the most from smoking cessation interventions, early detection, or chemoprevention. OBJECTIVE: To evaluate whether the presence of emphysema on low-radiation-dose CT (LDCT) of the chest is an independent risk factor for lung cancer. METHODS: The study used data from a prospective cohort of 1,166 former and current smokers participating in a lung cancer screening study. All individuals underwent a baseline LDCT and spirometry followed by yearly repeat LDCT studies. The incidence density of lung cancer among patients with and without emphysema on LDCT was estimated. Stratified and multiple regression analyses were used to assess whether emphysema is an independent risk factor for lung cancer after adjusting for age, gender, smoking history, and the presence of airway obstruction on spirometry. RESULTS: On univariate analysis, the incidence density of lung cancer among individuals with and without emphysema on LDCT was 25.0 per 1,000 person-years and 7.5 per 1,000 person-years, respectively (risk ratio [RR], 3.33; 95% confidence interval [CI], 1.41 to 7.85). Emphysema was also associated with increased risk of lung cancer when the analysis was limited to individuals without airway obstruction on spirometry (RR, 4.33; 95% CI, 1.04 to 18.16). Multivariate analysis showed that the presence of emphysema (RR, 2.51; 95% CI, 1.01 to 6.23) on LDCT but not airway obstruction (RR, 2.10; 95% CI, 0.79 to 5.58) was associated with increased risk of lung cancer after adjusting for potential cofounders. CONCLUSIONS: Results suggest that the presence of emphysema on LDCT is an independent risk factor for lung cancer.

La tomografía computarizada multicorte (TCMC) permite estudiar las arterias coronarias de forma no invasiva. A pesar de la elevada resolución espacial y temporal de los equipos de sesenta y cuatro cortes (TCMC- 64) esta técnica no se encuentra exenta de limitaciones. La tomografía computarizada de doble fuente (TCDF) permite estudiar las arterias coronarias con gran calidad diagnóstica en todos los sujetos independien- temente de su frecuencia cardiaca sin necesidad, por tanto, de emplear betabloqueantes. En este trabajo se describen los estudios por TCDF de tres pacientes con elevada frecuencia cardiaca y gran variabilidad del ritmo. Se demuestra la utilidad de esta técnica para obtener estudios de excelente calidad diagnóstica en casos en que la coronariografía por TCMC-64 convencional presenta limitaciones. INGLÉS: Multidetector computed tomography (MDCT) has been demonstrated to be a very useful technique to non-invasively study coronary arteries. Despite the high spatial and temporal resolution of 64-slice MDCT scanners, this technique has several limitations. Dual-source computed tomography (DSCT) allows to study coronary arteries with excellent diagnostic quality in all subjects independent of the heart rate, thus avoiding the use of beta-blockers. In this article DSCT studies from three subjects with elevated heart rate and irregular heart rhythm are described. Usefulness of this technique to obtain studies of excellent quality in cases in which conventional 64-row-MDCT might present limitations is emphasized.

Rationale and Purpose: Low-dose spiral computerized axial tomography (spiral CT) is effective for the detection of small early lung cancers. Although published data seem promising, there has been a significant degree of discussion concerning the potential of overdiagnosis in the context of spiral CT–based screening. The objective of the current study was to analyze the phenotypic and genetic alterations in the small pulmonary malignancies resected after detection in the University of Navarra/International Early Lung Cancer Action Project spiral CT screening trial and to determine whether their malignant molecular features are similar to those of resected lung tumors diagnosed conventionally. Experimental Design: We analyzed 17 biomarkers of lung epithelial malignancy in a series of 11 tumors resected at our institution during the last 4 years (1,004 high-risk individuals screened), using immunohistochemistry and fluorescence in situ hybridization (FISH). A parallel series of 11 gender-, stage-, and histology-matched lung cancers diagnosed by other means except screening was used as control. Results: The molecular alterations and the frequency of phenotypic or genetic aberrations were very similar when screen-detected and nonscreen-detected lung cancers were compared. Furthermore, most of the alterations found in the screen-detected cancers from this study were concordant with what has been described previously for stage I-II lung cancer. Conclusions: Small early-stage lung cancers resected after detection in a spiral CT-based screening trial reveal malignant molecular features similar to those found in conventionally diagnosed lung cancers, suggesting that the screen-detected cancers are not overdiagnosed