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Aims Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA). Methods and results A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency. Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase. He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m2) and end-diastolic volume (57 ml/m2) together with reduced end-diastolic wall mass (51 g/m2). Right ventricle volumes were reduced too. In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course. Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders. A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME. Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart. Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery). Conclusions This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME. 770 Figure

We report an unusual case of a 35-year-old Ivorian migrant with an abdominal mass and medical history relevant for human immunodeficiency virus-2 positivity with a CD4/CD8 ratio of 0.63; Mantoux and lymphocyte stimulation tests (QuantiFERON) were positive. 3D-CT images revealed a voluminous non-homogeneous retroperitoneal mass in the right abdominal region presenting no significant contrast impregnation. Thoraco-abdominal aorta presented diffuse-altered morphology with multiple ectasias throughout its course and an aneurysm at the level of the subrenal tract. The patient underwent vascular surgery. Mycobacterium tuberculosis complex was detected by polymerase chain reaction performed on intraoperative tissue specimens. Postoperative course was uneventful. After surgery, 3D-CT images showed no signs of malfunction of the prosthesis. At last, at 6-month follow-up, the patient was well. Cross-sectional imaging techniques, such as contrasted-CT, are essential and allow for making diagnosis, assessing disease activity, and evaluating post-treatment condition. 3D reconstruction permits an appropriate patient care by means of an excellent visualization and staging of the disease process.

Background: Our study aimed to evaluate right ventricular (RV) morphology and strain (S) in the early stage of familial transthyretin (TTR) cardiac amyloidosis (CA). Methods and Results: Thirty-seven patients with transthyretin mutation underwent 99mTc-3,3-diphosphono-1,2 propanodicarboxylic acid (99mTc-DPD) scans and/or cardiac magnetic resonance (CMR) to identify TTR CA. Each patient underwent echocardiography to quantify RV dimensions, tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (sPAP), longitudinal (L) strain of the RV free wall, left ventricular (LV) septal thickness (ST), ejection fraction, E/E', LV global (G) L, radial (R), and circumferential (C) S. 99mTc-DPD and CMR revealed the accumulation in 22 of 37 patients (CA group) and no accumulation in 15 patients (no-CA group). Left ventricular (LV) septal thickness (ST) was higher (P < 0.0001) while LV ejection fraction and E/E' were lower (P < 0.05) in the CA group than the no-CA group. LV-global longitudinal strain (LS) was lower (P < 0.0001) in the CA-group than the no CA-group, whereas LV-global circumferential strain and LV-global radial strain were similar. The CA group showed higher values of RV dimensions (P < 0.05) and sPAP (0.02) and a lower (P = 0.002) TAPSE. Globally, RV-LS was lower (P = 0.005) in the CA group than the no-CA group. Basal and mid segments of the RV free wall showed a lower LS in the CA group than the no-CA group (P < 0.01), while apical S was similar between groups. Conclusions: RV deformation, particularly in basal and mid segments, is early impaired in CA.

Left ventricular intramyocardial fat (LV-IMF) is often found in patients with previous irreversible myocardial damage and may be detected by cardiac magnetic resonance (CMR). No data are currently available about the prevalence of LV-IMF in patients with previous myocarditis. Our aim was to assess the prevalence of LV-IMF in patients with previous myocarditis by repeating after3 years a follow-up CMR examination and to evaluate its clinical and prognostic role. Patients with clinical suspected myocarditis who underwent CMR within the first week from the onset of their symptoms and underwent repeated CMR were enrolled. LV-IMF was detected as areas of left ventricular intramyocardial "India ink" black boundary with or without a hyperintense core. Overall, in 235 patients with a definitive diagnosis of acute myocarditis, CMR was repeated after a median of 4 (3 to 6) years from symptom onset. LV-IMF positive patients (n = 35, 15%) presented greater ventricular volumes and more frequently a mid-wall late gadolinium enhancement than those without LV-IMF (both p0.05). Patients presenting major cardiac events (sudden cardiac deaths, resuscitated cardiac arrest, and appropriate implantable cardioverter-defibrillator-firing) at follow-up had a greater prevalence of LV-IMF than those without (55% vs 11%, p0.001). Patients with LV-IMF had a higher incidence myocarditis relapse (27% vs 9%, p = 0.003) and a greater risk of major cardiac events (p0.0001) than those without. At logistic regression analysis, LV-IMF was an independent predictor of major cardiac events. In conclusion, LV-IMF is not an uncommon finding in patients with previous myocarditis and is associated with worse ventricular remodeling and prognosis.

BACKGROUND The aim of present study was to assess left ventricular (LV) myocardial deformation and changes over time in patients with acute myocarditis (AM) with preserved ejection fraction detected by late gadolinium enhancement (LGE) magnetic resonance imaging. METHODS Thirty-five male patients with AM diagnoses and preserved systolic function based on cardiac magnetic resonance imaging (MRI) were prospectively enrolled. On admission, echocardiography with measurements of global and segmental longitudinal (LS) strains was performed both at the endocardial (ENDO) and epicardial (EPI) levels. Findings were compared to 25 control subjects. Twenty-six patients were also monitored over a 22-month follow-up (FU group). RESULTS On admission, global ENDO-LS was poorer in magnitude in AM (-19.2 ± 3.1) than in controls (-24.0 ± 1.05) (P

BACKGROUND We sought to assess left atrial (LA) morphology and function in patients with transthyretin cardiac amyloidosis (TTR-CA) and hypertrophic cardiomyopathy (HCM). Primarily, longitudinal deformation (reservoir) and pump function were the focus of vector-velocity strain echocardiography imaging. METHODS AND RESULTS The study group comprised 32 patients (mean age 57.7±15.4 years, 16 in each group), and 15 healthy controls. Diagnosis of TTR-CA was based on echocardiography and either gadolinium-enhanced (LGE) cardiac magnetic resonance (cMRI) or radionuclide imaging. At baseline, there were no differences in age, body surface area, blood pressure and risk factors among the groups. Left ventricular (LV) mass was greater in patients than in controls, and slight LA dilatation was found in the TTR-CA group. LA reservoir was 14.1±4.7% in TTR-CA, 20.0±5.6% in HCM, and 34.0±11.8% in controls (

Cardiomyopathies (Cs) are a heterogeneous group of myocardial diseases with structural and/or functional abnormalities.The aetiology is due to genetic-family substrate in most cases, however, the correct and detailed analysis of morphofunctional abnormalities (severity and distribution of hypertrophy, ventricular dilatation, ventricular dysfunction) and tissue characteristics (myocardial fibrosis, myocardial infiltration) are a crucial element for a definite diagnosis.Among the different diagnostic imaging modalities applied in clinical practice (echocardiography, nuclear medicine), cardiac magnetic resonance (CMR) has emerged as a non-invasive diagnostic tool having high ability to quantify systolic function and tissue abnormalities that represent the substrates of many Cs.The main added value of CMR is the ability to identify cardiomyopathies with respect to ischemic heart disease and, above all, to discriminate the major types of cardiomyopathies based on morpho-functional presentation patterns and the presence and location of myocardial fibrosis.Many CMR elements allow increasing diagnostic accuracy but CMR data should be integrated with an appropriate clinical and instrumental context.Computed Tomographic (CT) scan technology has showed a complementary role in patients having Cs and HF.In this chapter, the diagnostic, pathophysiologic and prognostic value of CMR and CT in heart failure due to the most common cardiomyopathies will be discussed.

Objectives Acute type B aortic dissection can have a stable course or evolve into aneurysm and subsequent adverse events. The aim of this systematic review was to analyze the morphologic predictors of an adverse course to establish their validity based on consistency of results. Methods Fifty-one studies were included in this review, reporting on aortic size, false lumen (FL) size, primary entry tear (ET) size and location, status of FL thrombosis, number of ETs, branch vessels involvement, and FL longitudinal extent. Results Some predictors showed good consistency, whereas others did not. Aortic size was the most investigated predictor. A larger diameter at presentation predicted worse outcomes, with few exceptions. Both FL size and size relative to true lumen size also predicted an adverse course, although a standardized measurement method was not used. Regarding primary ET size and location, evidence was sparse and somewhat conflicting. Although FL complete thrombosis was consistently associated with a more benign course, the role of partial thrombosis remained unclear and the concept of FL saccular formation might account for the inconsistency, but further evidence is needed. A higher number of re-entry tears was considered to be protective against false channel expansion, but results need to be confirmed. The predictive role of branch vessels involvement and FL longitudinal extent remain controversial. Conclusions Among several predictors of aortic growth and events in acute type B aortic dissection, controversial and even conflicting results have been described. Consistent evidence has been demonstrated only for two predictors: aortic size at presentation is associated with adverse events and total FL thrombosis has a protective role.

OBJECTIVES: Right ventricular (RV) myocarditis (MY) is unrecognized, and its prevalence is unknown. We evaluated the prevalence of RV involvement in acute MY and its association with cardiac events (cardiac death, cardiac arrest, ventricular assist device, transplantation, and appropriate ICD intervention). METHODS: We enrolled 151 patients who underwent cardiac magnetic resonance for clinical suspicion of acute MY. The CMR protocol included T2-STIR images for edema detection, post-contrast cine-SSFP for hyperemia detection and late gadolinium enhancement (LGE) images. RESULTS: Signs of RV MY were found in 27 patients (17.8%): RV edema at T2-STIR in all of these 27 patients; RV LGE was detected in 11 patients (7.3%). The median RV myocardial segment involved was 2 (1-3). In 13 patients, RV edema was in direct continuity with LV edema of septum and inferior wall or with anterior septum and anterior wall. In 2 patients RV myocarditis was found without any signs of LV involvement. Patients with RV MY had higher RV end-diastolic volume index (p = 0.04) and RV mass index (p = 0.03), and lower RV ejection fraction (p

Cardiac involvement is not rare in systemic amyloidosis and is associated with poor prognosis. Both (99m)Tc-diphosphonate imaging and cardiac MRI with late gadolinium enhancement are considered valuable tools in revealing amyloid deposition in the myocardium; however, to our knowledge, no comparative study between the two techniques exists. We compared findings of these two techniques in patients with transthyretin-familial amyloid polyneuropathy (FAP).Eighteen patients with transthyretin-FAP underwent (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement. Images were visually evaluated by independent readers to determine the presence of radiotracer accumulation or late gadolinium enhancement-positive areas at the level of cardiac chambers.Interobserver agreement ranged from moderate to very good for (99m)Tc-diphosphonate imaging findings and was very good for findings of MRI with late gadolinium enhancement. Left ventricle (LV) radiotracer uptake was found in 10 of 18 patients, whereas LV late gadolinium enhancement-positive areas were found in eight of 18 patients (χ(2) = 0.9; p = 0.343). One hundred fifty-nine LV segments showed (99m)Tc-diphosphonate accumulation, and 57 LV segments were late gadolinium enhancement positive (p0.0001). Radiotracer uptake was found in the right ventricle (RV) in eight patients and in both atria in five patients, whereas MRI showed that RV was involved in three patients and both atria in six patients; the differences were not statistically significant (RV, p = 0.07; atria, p = 1). Intermodality agreement between (99m)Tc-diphosphonate imaging and MRI ranged from fair to good.Our study shows that, although (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement have similar capabilities to identify patients with myocardial amyloid deposition, cardiac amyloid infiltration burden can be significantly underestimated by visual analysis of MRI with late gadolinium enhancement compared with (99m)Tc-diphosphonate imaging.

Pericardial cysts are rare, usually benign congenital anomalies but may also be acquired. They represent 6% of mediastinal masses and 33% of all mediastinal cysts.1) The vast majority are asymptomatic and are usually found incidentally on chest radiographs, computed tomography scans, magnetic resonance images, or echocardiography.2) Large pericardial cysts may cause compression on adjacent structures and organs, resulting in dyspnea, chest pain, or persistent cough.3) There have been reports of cyst rupture, cardiac compression, atrial fibrillation, and even sudden cardiac death from these cysts, although these complications are uncommon.4) A 55-year-old Italian dialysis patient with a shortness of breath, asthenia and excessive fatigability was referred to our institution. He had history of pericarditis, myocarditis and massive pleural effusion. His electrocardiogram showed sinus rhytm. Transthoracic echocardiography (TTE) revealed normal left and right ventricular systolic performance, with normal wall thicknesses and chamber sizes and a pericardial thickening. Color Doppler imaging showed a mild mitral and tricuspid regurgitation. Apical and subcostal views of TTE showed an oval echolucent structure at the right cardiophrenic angle, minimally compressing the right atrium, and of approximately 10 × 4 cm, consistent with a pericardial cyst (Fig. 1). Cardiac magnetic resonance (CMR) confirmed echocardiography findings, showing the presence of the pericardial cyst with several fibrinous strands inside associated with right-sided massive pleural effusion. Late gadolinium-enhanced CMR images showed intramural myocardial enhancement in anterior and inferior wall and enhancement of pericardium, as an expression of myocardial and pericardial inflammation (Fig. 2). The patient was treated conservatively because of high surgical risk attributed to severe kidney failure. A repeated TTE with the apical 4-chamber view at 20 months later showed minimal increase in the size of the pericardial cyst. The discovery of a pericardial cyst obliges the clinician to perform a broad differential diagnosis with a coronary artery aneurysm, dextrocardia, malignancy, and even pneumonia.5) CMR may help in this diagnosis. Fig. 1 Echocardiographic evaluation revealed a pericardial cyst in the inferior wall of the left ventricle. Fig. 2 Vertical long-axis (A and D) and short-axis (B, C, E, and F) cardiac magnetic resonance (CMR) images of pericardial cyst in patient with pericarditis, myocarditis and massive pleural effusion. Cyst (white asterisks) has low signal intensity on T1-weighted ...

Left atrium can be involved by amyloid deposition in familial amyloid polyneuropathy (FAP). The aim of our study is to assess left atrium function in atrial amyloidosis.Twenty-eight FAP patients (53 ± 12 years) and a control group of 22 asymptomatic individuals (49 ± 11 years) underwent strain echocardiography and cardiac magnetic resonance (CMR). CMR by late gadolinium enhancement (LGE) was used to assess the left atrium amyloid deposition, whereas strain echocardiography was used to quantify the left atrium deformation. The following atrial longitudinal strain (ALS) parameters were assessed: peak at the end of ventricular systole (peak-ALS), peak at early diastole (early-ALS), negative peak in late diastole, precontraction (prec)-ALS (difference between peak-ALS and early-ALS), and late ALS (sum of negative peak and prec-ALS).CMR showed atrial LGE in 14 FAP patients (LGE-atrial group), whereas 14 FAP patients showed no LGE (no-LGE-atrial group). Peak-ALS was significantly lower in the LGE-atrial group (22.8 ± 13%) compared with the no-LGE-atrial group (59.6 ± 33.1%; P = 0.001) and controls (47.4 ± 16.4%; P = 0.001). Early-ALS was lower in the LGE-atrial group (10.2 ± 6.2%) compared with the controls (26.3 ± 11.9%; P = 0.02) and the no-LGE-atrial group (30.2 ± 22.4%; P = 0.01). Prec-ALS was lower (P = 0.001) in the LGE-atrial group (12.6 ± 7.8%) compared with the no-LGE-atrial group (26.2 ± 15%). Conversely, late-ALS was higher (P = 0.04) in the no-LGE-atrial group (22.8 ± 12.3%) compared with the controls (13.9 ± 9%); no significant differences were found in the negative peak among groups.Patients with atrial amyloidosis have an adverse left atrium remodeling associated with left atrium dysfunction. Left atrium assessment may provide useful information in the clinical and prognostic stratification of amyloidotic patients.

Rational and Objectives To investigate whether a nonlinear-blending algorithm improves tumor conspicuity and image quality in the evaluation of renal masses at dual-energy computed tomography (DECT) during nephrographic phase of enhancement. Materials and Methods The Institutional Review Board approved this retrospective study from archival material from patients consenting to the use of medical records for research purposes. A retrospective review of contrast-enhanced abdominal DECT scans in 45 patients (mean age, 59.5 years; range, 24–84 years) was performed. DECT data were reconstructed using nonlinear and linear blending. A region of interest was located within tumors and adjacent normal parenchyma; attenuation differences and contrast-to-noise ratios (CNRs) were calculated for renal masses on nonlinear- and linear-blended images. The two datasets were subjectively compared in terms of tumor detection and image quality. An exact Wilcoxon's matched pairs signed rank and marginal homogeneity tests were used to test whether differences in attenuation, CNR, and subjective assessment were greater using nonlinear blending. Results The mean difference in attenuation for renal masses and adjacent portion of renal parenchyma was 138.4 Hounsfield units ± 28.9 SD using nonlinear blending, and 121.6 HU ± 18.0 SD using linear blending ( P P P Conclusion Compared with standard linear blending, nonlinear-blending algorithm improves tumor conspicuity and image quality in renal masses at DECT evaluation during nephrographic phase of enhancement.

Delayed-contrast-enhancement (DCE) magnetic resonance imaging (MRI) can identify areas of myocardial damage in patients with acute myocarditis (AM). The aim of this study was to assess the electrocardiographic findings in AM diagnosed by DCE-MRI. Eighty-one patients (72 men, 35 ± 13 years) with AM were prospectively enrolled. All of them underwent MRI and 12-lead-ECG recordings. In the admission electrocardiogram (ECG 1), as well as in that obtained 48 h later (ECG 2), the following parameters were analyzed: rhythm, PR, QRS, and QTc-intervals, intraventricular conduction, abnormal Q waves, ST segment elevation, and T wave inversion. On admission, 77 patients (95%) were in sinus rhythm, while four patients (6%) manifested severe arrhythmias. No difference between ECG 1 and ECG 2 was observed regarding abnormal Q waves, PR, QRS, and QTc-intervals. Electrocardiogram 1 was normal in 26 patients (32%, normal ECG group), and abnormal in 55 patients (68%, abnormal ECG group). ST elevation was found in 46 patients (57%), inverted T wave in seven patients (9%) and left bundle branch block (LBBB) in two patients (3%). Areas of DCE suggesting AM were found in each patient. No relationship concerning the location of the involved region (s) was found between ECG (leads with ST/T abnormalities) and MRI (areas showing DCE). The ECG in AM can either be normal or reflect abnormalities including arrhythmias, LBBB, ST segment elevation, and T wave inversion. The location of myocardial involvement deduced on the basis of ECG leads showing ST/T changes is not in close relationship with the areas of ventricular damage detected by MRI.

The progress in cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–11]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care. Increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention [12,13] as well as the role of the thromboembolism prophylaxis [14–24]. The increased thromboembolism risk in cancer patients [19,20] is influenced by the type of cancer, its stage and histology, the presence of thrombophilia, concomitant and previous treatments, metastatic-stage malignancy [25], vascular catheter presence [15], and paraneoplastic hypercoagulability [17,18,20,25]. Patient-, cancer-, and treatment-related factors should be taken under consideration in the assessment of individual venous thromboembolism risk [25]. We present a case of a right atrial mass in a 57-year-old Italian woman. She reported a history of diabetes mellitus, a history of smoking, a sotalol treatment and a lymphoma chemotherapy treatment. Echocardiographic evaluation revealed a right atrial mass (Fig. 1) [26,27]. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network [26]. Cardiac magnetic resonance [27,28] identified right atrial mass as an atrial thrombus

Objective: To evaluate the accuracy of a semiautomatic quantification of left ventricular (LV) volumes and ejection fraction (EF) using two-dimensional (2D) feature tracking imaging (FTI). Methods: Thirty-four consecutive subjects (11 patients with dilated cardiomyopathy, 13 with hypertrophic cardiomyopathy, and 10 subjects with no cardiac disease) underwent, on the same day, trans-thoracic echocardiography (TTE) examination, FTI, and cardiac magnetic resonance imaging (MRI), as gold standard, in order to quantify LV volumes and EF. The echocardiographic quantification of LV volumes and EF was determined from four- and two-chamber views using both standard TTE Biplane Simpson's method and a semiautomatic border detection based on FTI. Furthermore, the time for data analysis for each method was measured. Results: The time required for semiautomatic analysis of volumes and EF was significantly lower (P < 0.0001) by FTI (71 seconds) in comparison with standard biplane Simpson's method (93 seconds). LV volumes obtained by FTI were significant underestimated (P < 0.001) in comparison with MRI. Bland-Altman analysis of EDV and ESV using FTI and cardiac MRI showed a low level of agreement for EDV (mean difference = 40.8; SD = 39) and ESV (mean difference = 38.1; SD = 42). On the contrary, no significant difference between FTI and MRI in assessing the LVEF was found; furthermore, a very low bias (2 ± 12) by Bland-Altman analysis was found between FTI and cardiac MRI for the quantification of EF. Conclusion: Semiautomatic quantification of LV volumes using FTI allows an accurate, rapid, easy and reliable assessment of LV EF and a rough estimation of LV volumes. (Echocardiography 2010;27:791-797)

The purpose of this study was to describe the MR imaging findings of Nuck canal endometriosis (NCE).In a 10-year period, 486 out of 612 patients, with laparoscopically and/or surgically proven diagnosis of pelvic endometriosis, underwent MR imaging examination. The examinations were reviewed by two urogenital experienced radiologists working in consensus. Data analysis included: lesions location, size, morphological and signal intensity pattern, involvement of the adjacent muscles, and tendons.In 372 out of 486 patients an MRI diagnosis of endometriosis was made. NCE was found in eight patients. All the lesions were located on the right side. The mean size of the lesions was 2.5 cm (range 1.5-4.5 cm). Two patterns of NCE were found: type 1, prevalently cystic (n = 2); and type 2, prevalently solid with small scattered cysts within lesion (n = 6). In all the patients, hemorrhagic hyperintense cysts could be seen on T1-weighted images. In four patients, the lesions involved the inguinal canal, and in another four patients, the lesions were only outside the inguinal canal. Involvement of the abdominis rectus muscle was seen in two patients, and of the adductor common tendon in two patients.MR imaging permits the diagnosis of NCE as well as the evaluation of exact extension of the disease.

Transcaval ureter is a rare congenital anomaly characterized by an inferior cava vein duplication producing a vascular ring around the right ureter, usually determining hydroureteronephrosis. The knowledge of this vascular anomaly on imaging examinations permits to avoid erroneous diagnosis of retroperitoneal masses or adenopathy and preoperatively advise the surgeon of potential sources of complications. We describe a case of transcaval ureter studied with multidetector computed tomography. To our knowledge, this is the first case in which computed tomography multiplanar and volume-rendering reconstructions show this rare anomaly.

We report a case of coronary artery and aortic root aneurysms in a 50-year-old man with Marfan syndrome. The coexistence of these findings is uncommon and rarely reported. We underline the role of electrocardiographically gated computed tomography angiography in the diagnosis of coronary aneurysm in this category of patients.

Mitral annulus calcification may appear under different forms depending from its evolution stage: mitral annulus calcification; homogeneous calcified mass of the mitral valve; liquefaction necrosis of the mass; reduction or stability of the mass dimension. We report a large calcified mass located in between the posterior mitral valve leaflet and adjacent left ventricular myocardium suggesting the homogeneous calcified phase of the disease.

Cardiac amyloidosis is a rare, infiltrative cardiomyopathy that presents with thickened ventricular walls and progressive heart failure. The morphological findings and clinical features are shared with many other diseases (i.e. hypertrophic cardiomyopathy, 'athlete's heart,' Fabry disease, and hypertensive cardiomyopathy), and misdiagnosis occurs frequently. Cardiologists have many instruments that can help reach a correct diagnosis in a relatively short time. As tiles of a mosaic are placed to create an image, thoughtful and smart use of the different diagnostic tools available allows the opportunity to identify amyloid infiltration of the myocardium. When the myocardium is involved, prognosis is poor, so identification of its involvement is crucial for disease management. The diagnostic process begins with an accurate evaluation of clinical elements and includes cardiovascular imaging (echocardiography, magnetic resonance, and nuclear medicine), electrocardiography, serological assays, and myocardial biopsy; only the appropriate integration of these instruments can reveal the diagnosis to an expert physician. The latest improvements in non-invasive diagnostic techniques with increased diagnostic power have reduced the need for biopsy.

We describe the case of a 34-year-old man with a history of asthenia and excessive fatigability. Transthoracic echocardiography showed a mass in the right ventricular outflow tract with a peak systolic gradient of 52 mmHg. Contrast-enhanced CT confirmed the presence of a lobulated mass, which extensively filled the anterior mediastinum, infiltrating the pulmonary artery trunk up to occupying the right ventricular outflow tract. CT-guided biopsy revealed primary mediastinal B-cellular lymphoma. The patient underwent chemotherapy, achieving complete remission of the disease at the 12-month follow-up, while the gradient across the pulmonary artery dropped from 52 mmHg to 14 mmHg.

MOTS CLES Arc aortique ; Anneau vasculaire ; Imagerie par resonance A right-sided aortic arch is an aortic arch that crosses over the right main stem bronchus instead of the usual left main stem bronchus. A vascular ring is a malformation where vascular branches encircle the trachea and oesophagus. When the circle around the trachea and oesophagus is incomplete, the malformation is called vascular sling. In most cases, a right-sided aortic arch is present. In a double aortic arch (one of the most common vascular ring malformation patterns), the two arches encircle the trachea and oesophagus. Symptoms of vascular ring, including stridor, wheezing and dysphagia, are due to compression of the trachea or oesophagus. If compression is minimal, vascular rings may be asymptomatic and diagnosed as incidental findings. A 37-year-old man presented with a history of chest discomfort, progressive mild dyspnoea on exertion and intermittent dysphagia for solids and liquids. Chest X-ray showed right aortic arch. Magnetic resonance (MR) angiography showed right aortic arch, separated origin of right carotid and right subclavian arteries, and common origin of left carotid and left subclavian

A 35-year-old patient previously operated when a child for right ventricular (RV) rhabdomyoma was submitted to cardiac magnetic resonance (CMR) that showed a dilated RV and a small contractile cavity in the inferior left ventricular (LV) wall suggestive for diverticulum. This report shows the first description of a simultaneous evidence of LV diverticulum and previous rhabdomyoma, and furthermore highlights the important role of CMR for an easy detection of this congenital abnormality.

A 73-year-old man presented to our department for ischemic alterations appeared during a stress electrocardiogram. The diagnostic process including coronary angiography, cardiac computed tomography and echocardiogram revealed an anomalous origin of the left main coronary artery from the commissural region between the left and the non-coronary Valsalva sinus associated with non-obstructive accessory mitral valve tissue. Although these malformations are relatively common the association is not described in literature to date.

The purpose of this study was to assess the value of dual-source dual-energy CT in the evaluation of complex cystic renal masses.Seventy patients underwent contrast-enhanced dual-energy CT that included true unenhanced images acquired in single-energy mode, corticomedullary phase images acquired in dual-energy mode, and nephrographic phase images acquired in single-energy mode. Virtual unenhanced, blended weighted-average, and color-coded iodine overlay images were reconstructed. The acceptance level and image quality of virtual and true unenhanced images were evaluated. Contrast enhancement on both true unenhanced or blended weighted-average images and color-coded iodine overlay images was evaluated with both calculation in regions of interest and use of confidence level scales. Radiation dose parameters were estimated.Virtual unenhanced images of 70 lesions (97.2%) and true unenhanced images of 72 lesions (100%) were judged acceptable (p = 0.5). The mean quality score of virtual unenhanced images was 2.0 ± 0.7 and of true unenhanced images was 1.5 ± 0.5 (p0.001). Mean contrast enhancement measured on true unenhanced and blended weighted-average images was 45.9 ± 15.9 HU (range, 21-78 HU) and on color-coded iodine overlay images was 47.3 ± 16.8 HU (range, 22-75 HU) with no significant differences. Enhancement was excluded on color-coded iodine overlay images with a significantly (p0.03) higher level of confidence than it was on true unenhanced and blended weighted-average images. The mean dose reduction with use of a combined dual- and single-energy dual-phase CT protocol was 29.1% ± 11.9% (p0.001).Dual-source dual-energy CT is a reliable imaging technique in the evaluation of complex cystic renal masses. True unenhanced images can be replaced by virtual unenhanced images with considerable radiation dose reduction. The color-coded iodine overlay technique is a useful tool for both excluding and identifying endocystic enhancement.

To describe the magnetic resonance imaging (MRI) pattern of muscle involvement and disease progression in five patients with late-onset Charcot-Marie-Tooth (CMT) disease type 2 F, due to a previously unknown mutation. Five patients (three males, two females) underwent MRI of the lower limbs to define the pattern of muscle involvement and evaluate the muscle fat fraction (MFF) of residual thigh muscle with gradient-echo (GRE) dual-echo dual-flip angle technique. Evaluation of fatty infiltration both by visual inspection and MFF calculation was performed. A proximal-to-distal gradient of muscle involvement was depicted in male patients with extensive muscle wasting of lower legs, less severe impairment of distal thigh muscles, and sparing of proximal thigh muscles. A peculiar phenotype finding was that no or only slight muscle abnormalities could be found in the two female patients. We described the pattern of muscle involvement and disease progression in a family with CMT disease type 2 F. GRE dual-echo dual-flip angle MRI technique is a valuable technique to obtain a rapid quantification of MFF.

Considering that multiple imaging examinations are often necessary for monitoring Crohn's disease (CD) activity and severity in order to guide and monitor appropriate treatment, the ideal imaging test would be reproducible, well tolerated by patients, and free of ionizing radiation. For these reasons recent studies have highlighted the role of a magnetic resonance imaging (MRI) technique optimized for small bowel imaging in the evaluation of small bowel disorders. In this regard there are two main methodological approaches represented by MR enterography, following administration of an oral contrast medium, and MR enteroclysis, following administration of contrast medium through a nasojejuneal tube. MRI may be used to demonstrate the pathologic findings and complications of CD. In particular, MR has excellent sensitivity and specificity, ranging from 88%–98% and 78%–100%, respectively, for the detection of active inflammation, wall thickening, ulcerations, increased wall enhancement, increased vascularity, perienteric inflammation, and reactive adenopathy. MR also allows more accurate identification of associated complications including penetrating and fibrostenotic disease as well as the more rare extraintestinal manifestations that are usually associated with severe and longstanding intestinal inflammation, the latter often guiding the therapeutic approach. In the progression of CD some rare complications can occur that, to our knowledge, were only briefly or never mentioned in the radiological literature regarding MR enterography or enteroclysis and in which the application of these techniques play a key role. (Inflamm Bowel Dis 2010;)

The progress in cancer knowledge and treatment has led to a new frontier: cardio-oncology [1–27]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care [1,12,17]. We present a case of a 57year-old Italian man complaining about episodes of cardioinhibitory vasovagal syncope [28–30]. He reported a history of atrial fibrillation, diabetes mellitus, smoking, a sotalol treatment, a chemotherapy treatment and a laryngeal tracheostomy for laryngeal cancer. Echocardiographic evaluation revealed a biatrial dilatation, a fibrocalcification of a three-leaflet aortic valve with a severe aortic stenosis [AVA = 0.8 cm, transvalvular mean gradient = 51 mm Hg] [Fig. 1] and a moderate aortic regurgitation [PHT= 415ms], and amildmitral regurgitation. Results of a 24-hour Holter monitoring showed several pauses of at least 1.5 s and up to 2.5 s, and 68 pauses of longer than 2.5 s (max pause of 3360 ms). Computer tomography imaging showed progressive stenosis of the left internal carotid artery and the total occlusion of the left jugular vein due to neck neoplastic mass [Fig. 2]. A pacemaker implantation was successfully performed.

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease affecting both intramyocardial and epicardial coronary arteries and is observed in patients during long-term survival after cardiac transplantation. We report a case of CAV complicated with silent transmural myocardial infarction and massive left ventricular thrombus formation associated with silent pericarditis and with ischemic and non-ischemic scar tissue, as detected by cardiac magnetic resonance imaging (CMRI). The authors suggest CMRI as an additional technique along with echocardiography during follow-up of heart transplant recipients. CMRI may contribute to the early identification of areas of myocardial wall abnormalities suggestive of CAV, thus guiding diagnosis and prompt percutaneous treatment.

Background— Experimental data show that the right ventricle (RV) is more resistant to ischemia than the left ventricle. To date, limited data are available in humans because of the difficulty of discriminating reversible from irreversible ischemic damage. We sought to characterize RV ischemic injury in patients with reperfused myocardial infarction using cardiovascular magnetic resonance. Methods and Results— In 3 tertiary centers, 242 consecutive patients with reperfused acute ST-segment elevation myocardial infarction were studied with cardiovascular magnetic resonance at 1 week and 4 months after myocardial infarction. T2-weighted and postcontrast cardiovascular magnetic resonance scans were used to depict myocardial edema and late gadolinium enhancement, respectively. Early after infarction, RV edema was common (51% of patients), often associated with late gadolinium enhancement (31% of patients). Remarkably, RV edema and late gadolinium enhancement were found in 33% and 12% of anterior left ventricular infarcts, respectively. Baseline regional and global RV functions were inversely related to the presence and extent of RV edema and RV late gadolinium enhancement. At follow-up, a significant decrease in frequency (25/242 patients; 10%) and extent of RV late gadolinium enhancement was observed ( P P= 0.003). Conclusions— Early postinfarction RV ischemic injury is common and is characterized by the presence of myocardial edema, late gadolinium enhancement, and functional abnormalities. RV injury is not limited to inferior infarcts but is commonly found in anterior infarcts as well. Cardiovascular magnetic resonance findings suggest reversibility of acute RV dysfunction with limited permanent myocardial damage at 4-month follow-up.

A 27-year-old man was transferred to our hospital because of heart failure. He had been diagnosed with dilated cardiomyopathy 6 months ago. Since at initial echocardiography a left ventricular (LV) apical thrombus (size 3 cm) was shown, the patient was treated with oral anticoagulation therapy. To exclude non-compaction cardiomyopathy of the LV, he was referred to cardiac magnetic resonance (CMR). Cine CMR showed a severely dilated and dysfunctional LV (EDV: 329 mL, EF: 15%) with severe diffuse …

In this report the authors deal with the combined approach of last generation computed tomography and color Doppler echocardiography to make a diagnosis of myocardial coronary bridging in a young patient with left ventricular hypertrophy. Double-source tomographic scan precisely identified the tunnelled segment of the left descending coronary artery (the first diagonal branch), whereas echocardiography allowed recognising diastolic and systolic velocity just in this vessel. Coronary velocity throughout the bridged artery was not particularly increased at rest and late after exercise, even if the patient had ST-T changes during cycling test. These findings likely support a benign pathophysiological significance of isolated bridging of secondary coronary branches.

Magnetic resonance imaging (MRI) showed high accuracy in the diagnosis of many inflammatory cardiac diseases. We report a case of a patient where cardiac MRI was able to identify inflammation of myocardium, pleura and pulmonary parenchyma.

We report an echocardiographic pitfall, where a hypoecogenic area mimicking a pleural effusion was detected by CMR as an area of normal pulmonary parenchyma between the posterior left atrial wall and the dilated right pulmonary vein.