Radiologic findings in heart-lung transplantation: a preliminary experience

The chest radiographic findings and pulmonary radionuclide studies of four patients who underwent heart-lung transplantation between May 1983 and June 1986 were reviewed retrospectively. The two long-term survivors both developed bronchiolitis obliterans (presenting at 32 months postoperatively in the first patient and 14.5 months postoperatively in the second). The etiology of this is likely to be multifactorial and includes pulmonary rejection which may develop without concomitant cardiac rejection. The radiologist must be alert to this complication in heart-lung transplantation. The chest radiographs in our two patients showed diminution of peripheral bronchovascular markings and overinflation. The importance of careful screening of the radiographs of potential donors to detect pneumonia is emphasized. In one patient, a unilateral pneumothorax spread contralaterally due to the absence of normal anatomic barriers. The "reimplantation response" was not a prominent feature and was seen in one patient only. This response has been observed in heart-lung transplant recipients during the second postoperative week. The radiologic appearance is that of interstitial edema not explained by any clinical or hemodynamic findings.     

Bronchiolitis obliterans after lung transplantation: findings at chest radiography and high-resolution CT. The Toronto Lung Transplant Group

Although bronchiolitis obliterans (BO) is seen commonly after heart-lung transplantation, its occurrence after lung transplantation appears to be relatively infrequent. In the 55 single- and double-lung transplantations performed at Toronto General Hospital, 41 patients have survived longer than 3 months and four (10%) have developed pathologically proved BO. Chest radiographic findings in these four patients included slight to moderate decreased peripheral vascular markings (n = 3), slight to moderate volume loss (n = 2), subsegmental atelectasis (n = 2), and new, thin, linear, irregular areas of increased opacity (n = 2). High-resolution computed tomography (HRCT) demonstrated mild peripheral bronchiectasis (n = 4) and decreased peripheral vascular markings (n = 3). Although the radiographic and HRCT findings did not appear to be specific for posttransplantation BO, they may be of value in suggesting the diagnosis of BO within this patient population.     

Shifting pneumothorax after heart-lung transplantation.

Heart-lung transplantation involves the total replacement of two of the most complex organs of the thoracic cavity. This procedure is usually reserved for patients with failure of both systems, such as in primary pulmonary hypertension or chronic Eisenmenger physiology. The en bloc replacement of the heart and lungs leaves an open communication between the two sides of the thorax that may allow air or fluid to shift from one side to the other. To evaluate this possibility, the authors reviewed the chest radiographs of 25 heart-lung transplant recipients for signs of rapidly changing pneumothoraces that could not be explained by the conventional dynamics of pleural physiology. A series of postoperative radiographs showed unusual shifting or apparently rapid disappearance of pneumothoraces in eight patients. Decompression of a pneumothorax with a contralateral chest tube was a phenomenon observed in six of these patients.     

Bronchiolitis obliterans in heart-lung transplantation patients: radiologic findings in 11 patients

Patients who survive the postoperative period after combined heart-lung transplantation are at risk for developing progressive airway damage consisting of central bronchiectasis and bronchiolitis obliterans. The cause of these abnormalities is uncertain, but they are thought to represent a form of chronic rejection. The chest radiographs and medical records of 11 transplantation patients with proved bronchiolitis obliterans were reviewed retrospectively. A pathologic diagnosis was made by open-lung biopsy (five patients), transbronchial biopsy (three patients), and autopsy (two patients). Clinical criteria alone were used for diagnosis in one patient. In all patients, the chest radiographs showed parenchymal abnormalities consisting of linear-nodular, nodular, confluent nodular, or diffuse alveolar opacities. Radiographic evidence of central bronchiectasis was present in nine of the 11 patients. This feature was not present on chest radiographs of five randomly selected asymptomatic transplant patients. We conclude that the parenchymal lung changes in bronchiolitis obliterans in transplant patients are nonspecific and are radiographically indistinguishable from other infectious and noninfectious complications. The presence of central bronchiectasis (nine of the 11 patients) may be a distinctive radiographic finding in this group of patients.     

Regional pulmonary perfusion following human heart-lung transplantation

Ventilation and perfusion scans were obtained in six subjects who had undergone heart-lung transplantation with consequent denervation of the cardiopulmonary axis. Two of the subjects had developed obliterative bronchiolitis, which is believed to be a form of chronic rejection. Their pulmonary function tests demonstrated airflow obstruction and their scintigraphic studies were abnormal. In the remaining four subjects without obstructive airways disease, ventilation and planar perfusion scans were normal. Single photon emission computed tomography imaging of pulmonary perfusion in these patients revealed a layered distribution of blood flow indistinguishable from that of normal individuals. It is concluded that neurogenic mechanisms have little influence on the pattern of local pulmonary blood flow at rest.     

Acute lung rejection after heart-lung transplantation: correlation of findings on chest radiographs with lung biopsy results

This retrospective study was performed to determine if the chest radiograph could serve as a predictor for acute lung rejection in heart-lung transplantation patients. The findings on chest radiographs were correlated with the results of transbronchial biopsies in 16 heart-lung transplantation patients. The chest radiographs immediately preceding 83 biopsies were evaluated for a variety of findings. The histopathologic results of the lung biopsies were divided into five categories: (1) acute lung rejection (n = 25); (2) suggestive, but not diagnostic, of acute lung rejection (n = 8); (3) nonspecific (n = 26); (4) infection (n = 17); and (5) normal lung (n = 9). Biopsies from two patients showed both acute lung rejection and cytomegalovirus infection and were included in both categories. These histopathologic results were then correlated with the radiologic observations. We found that the combination of septal lines and new or increasing pleural effusions, without concomitant increase in cardiac size or vascular pedicle width, or evidence of vascular redistribution, indicated acute lung rejection with a sensitivity of 68% (17/25), specificity of 90% (52/58), and overall accuracy of 83% (69/83). We conclude that the chest radiograph is a useful indicator of acute lung rejection.     

Iatrogenic bilateral pneumothorax following unilateral transbronchial lung biopsy

Bilateral pneumothoraces are recognized complications of thoracic procedures in patients who have undergone heart or heart-lung transplantation. Bilateral simultaneous pneumothoraces developing following a unilateral transbronchial lung biopsy in the absence of previous thoracic surgery has not been reported previously.     

Bone marrow transplantation in patients with multiple myeloma: prognostic significance of MR imaging

OBJECTIVE. This study in myeloma patients treated with myeloablative therapy and bone marrow transplantation assessed the prognostic value of MR imaging before and after treatment of the bone marrow and the prognostic value of an index reflecting changes on MR images obtained before and after treatment. SUBJECTS AND METHODS. MR images (T1-weighted images before and after injection of gadolinium and T2(*)-weighted images) of the spine and pelvis were obtained 1 month before and 1 month after marrow transplantation in 25 consecutive patients with stage III myeloma. Pre- and posttreatment MR imaging patterns of marrow involvement (normal, focal, diffuse), number of focal lesions, and a "marrow evolution index" (0-8 on the basis of comparison of the lesions [number, size, contrast enhancement] and of the surrounding marrow background on pre- and posttreatment MR images) were determined. Hematologic and MR imaging parameters were correlated with the quality of response to treatment (complete versus partial remission) and with relapse-free and overall survival. RESULTS. Response quality did not differ among categories of patients determined on the basis of MR images. Individual MR imaging parameters did not correlate with response duration and survival. Patients with a low marrow evolution index had significantly longer relapse-free (p < 10(-3)) and overall survival (p = 0.005) than patients with a high index. CONCLUSION. Individual MR imaging parameters before and after treatment had no prognostic significance in our series of myeloma patients treated with marrow transplantation. Comparison of MR images before and after treatment using a marrow evolution index may help predict response duration and survival.     

Radiological and clinical findings of pulmonary aspergillosis following solid organ transplant

AIM: To evaluate the radiological and clinical findings in patients with pulmonary aspergillosis after solid organ transplantation. MATERIALS AND METHODS: This study included 13 consecutive patients (five liver, four kidney, and four heart transplant; 10 male and three female; median age 54 years; range 13-63 years) with histologically confirmed pulmonary aspergillosis after solid organ transplantation at a tertiary referral hospital. Chest radiographs and computed tomography (CT) examinations performed for diagnosis were available in all patients. Radiological findings, such as lesion characteristics, location, and associated findings, were assessed retrospectively by two radiologists. The changes in radiological findings and clinical response after treatment were also assessed. Clinical findings, such as time of onset, initial symptoms, clinical course, and laboratory findings, were reviewed. RESULTS: The most common radiographic and CT findings were pulmonary nodules or masses (n=12). The number of nodules or masses was less than 10 in eight patients. Associated findings were surrounding ground-glass opacity (n=4), central low density (n=8), central air cavity (n=5), and air bronchogram (n=3). Follow-up radiographs and/or CT after treatment showed improvement in eight patients, persistence in two, and deterioration in three. The onset time of pulmonary aspergillosis was a median of 32 days (range 15-165 days). The most common symptom at diagnosis was fever (n=6). Ten of 13 patients did not have leucopaenia. There were two aspergillosis-associated deaths during the follow-up period. CONCLUSION: The most common radiological finding of pulmonary aspergillosis after solid organ transplantation is multiple nodules or masses, which commonly appear within 1 month following transplantation.     

A long-acting calcium antagonist over one year did not improve BMIPP myocardial scintigraphic imagings in patients with pure coronary spastic angina

BACKGROUND: Calcium antagonists (Ca) have been effective in reducing angina attacks in patients with variant angina. However, there are no reports regarding the effectiveness of Ca on myocardial fatty acid metabolic images in patients with pure coronary spastic angina (CSA). OBJECTIVES: This study sought to examine the correlation between myocardial fatty acid metabolic images and the medical treatment of Ca in patients with pure CSA. METHODS AND RESULTS: This study included 35 consecutive patients (28 men, mean age of 66 +/- 10 years) with angiographically confirmed coronary spasm and no fixed stenosis. Long-acting Ca was administered to all 35 patients. Isosorbide dinitrate /nicorandil/another Ca/beta-bloker were administered when chest pain was not controlled. Using an iodinated fatty acid analogue, 15-(p-[iodine-123]iodophenyl)-3-(R,S)methylpentadecanoic acid (BMIPP), myocardial scintigraphies with intravenous adenosine triphosphate infusion were performed before cardiac catheterization and 12 mo after medical therapy. According to the medical control states, these 35 patients were classified into 3 groups; response (disappearance of angina attacks, 12 pts, 60 +/- 11 years), partial response (angina attacks < 4/mo, 12 pts, 67 +/- 10 years), and no response to therapy (angina attacks > or = 4/mo, 11 pts, 71 +/- 6 years). Reduced BMIPP uptake was observed in 24 (69%) of 35 patients before the treatment. Reduced BMIPP uptake was also found in 18 patients (51%) after 12 mo. Normal BMIPP uptake after 12 mo therapy was observed in about half (response: 42%, partial response: 58%, no response: 45%) of patients among the 3 groups. There was no difference regarding the value of washout rate (WOR) (response; 10 +/- 7 (before), 14 +/- 8% (12 mo)), partial response; 11 +/- 7, 10 +/- 5%, no response; 13 +/- 9, 14 +/- 8%) among the 3 groups. The defect scores of BMIPP in the three groups were not different during at least one year medical therapy. No difference regarding the distribution of other medical therapies (angiotensin converting enzyme inhibitors/angiotensin receptor blockers/beta-blockers/statins) was found. The administration of Ca and isosorbide dinitrate/nicorandil and 2 Ca was significantly higher in the poor than in the good control patients. CONCLUSIONS: Long-acting Ca over one year did not improve myocardial fatty acid metabolic images in patients with pure CSA. This may be related to silent ischemia.     

Functional and perceived response to intra-articular hyaluronan injection in patients with knee osteoarthritis: persistence of treatment effects over 5 months

Intra-articular injections of hyaluronic acid are currently indicated as a symptom-modifying treatment for knee osteoarthritis to palliate symptoms and improve function. A series of three to five weekly injections are typically delivered once per week and a period of at least 6 months must pass between consecutive injection series. Little is known about why some patients do not respond to this treatment or about its effects on outcome measures recorded during functional activities. In addition to investigating short-term self-report and measured functional changes, the purpose of this study was to evaluate the persistence of treatment effects over the typical time interval between consecutive treatment series. According to the a priori definition for response to treatment, over two-thirds of patients experienced improved knee function during the typical period between series of intra-articular injection of hyaluronic acid while a one-third did not demonstrate a change in self-report scores. Differences in response were similarly seen between groups in functional tests. Many had immediate benefits and although some did not retain their gains, others experienced a delayed response in the following months. Knee flexion range of motion was related to self-report and tested function, and improvements in range of motion were associated with concurrent improvements in other functional measures across the testing period. A short functional test and knee-specific questionnaire may provide an index that provides an indication as to whether or not a particular patient is likely to respond to hyaluronan injections. Such information may provide valuable input when decisions are made regarding which treatment option is recommended to individuals with knee osteoarthritis.     

Nondysplastic nodules that are hyperintense on T1-weighted gradient-echo MR imaging: frequency in cirrhotic patients undergoing transplantation

OBJECTIVE: Our objective was to determine the frequency and MR imaging findings of nondysplastic nodules that are hyperintense on T1-weighted gradient-echo imaging in patients with cirrhosis who undergo liver transplantation. MATERIALS AND METHODS: Two observers retrospectively evaluated in-phase (4-5 msec), opposed-phase gradient-echo (2.0-2.4 msec), and turbo short tau inversion recovery (STIR) MR images in 68 patients with cirrhosis--but without dysplastic nodules or hepatocellular carcinoma--who underwent MR imaging at 1.5 T within 150 days before liver transplantation. The size, number, signal characteristics, and arterial enhancement pattern of nodules that appear hyperintense on T1-weighted gradient-echo images were evaluated as well as the presence or absence of signal loss on opposed-phase imaging. These imaging findings were correlated with pathologic findings of whole explanted livers. RESULTS: Eleven (16%) of 68 patients had at least one nondysplastic nodule that was hyperintense on T1-weighted MR imaging. Three patients had diffuse nondysplastic hyperintense nodules (>10 nodules) measuring less than 0.5 cm, and the remaining eight patients had 22 nondysplastic hyperintense nodules ranging in size from 0.5 to 2.5 cm (mean, 1.2 cm), of which 13 were isointense and nine were hypointense on turbo STIR images. No lesion lost signal on opposed-phase imaging or enhanced during the hepatic arterial phase. CONCLUSION: In cirrhotic patients undergoing liver transplantation, nondysplastic nodules that are hyperintense are common findings on T1-weighted gradient-echo MR imaging and do not lose signal intensity on opposed-phase imaging or enhance during the hepatic arterial phase. These nodules may be indistinguishable from dysplastic nodules.     

Arthroscopic second generation autologous chondrocyte implantation

A biodegradable, hyaluronian-based biocompatible scaffold was used for autologous chondrocyte transplantation. This prospective study analyzes a clinical outcome of 70 consecutive patients treated by arthroscopic autologous chondrocyte transplantation at minimum 24 months follow up (47 of these patients achieved minimum 36 months follow-up and 21 patients minimum 48 months follow-up) in order to establish clear indication criteria for this type of treatment. 31 of these patients presented isolated chondral lesions, while 39 patients with associated lesions (23 ACL lesions, 28 meniscal lesions, 1 varus knee) were treated during the same surgical procedure with cartilage harvesting. A statistically significant clinical improvement was shown just at 24 months and the second-look arthroscopy demonstrated a complete coverage of the grafted area with a hyaline cartilage-like tissue in 12 of 15 analyzed patients. A better clinical outcome was observed in young, well-trained patients and in traumatic lesions. Other factors, such as defect size, localization, previous and associated surgery did not influence significantly the results. This matrix autologous chondrocyte transplantation procedure simplifies the surgical procedure and can be performed arthroscopically, thus reducing surgical morbidity and recovery time. Level of evidence: Level IV (Prospective case series study)     

Cervical spine flexion patterns

Lateral projection flexion and extension radiographs of the cervical spine are stress views. They are necessary to evaluate unstable ligamentous injury, which may not be apparent on neutral unstressed films. As there is very little literature on the proper evaluation of these radiographic views, we reviewed 150 consecutive cases from our Emergency Department to define patterns of flexion. Four significantly different patterns emerged. No flexion at any level was seen in 24.7% of patients. A single flexion angle was seen in 24.7%. Two flexion angles, usually at consecutive levels, were present in 29.3% of patients, and 21.3% had three or more flexion angles. Correlation with clinical data suggests that attempted flexion with no significant angle or a single angle is abnormal and may indicate soft tissue (ligament or muscle) injury. Three or more flexion angles are thought to represent a normal pattern. The most common pattern, two flexion angles at consecutive levels, has not been previously described. We believe this pattern indicates less than full flexion and can be seen in individuals without significant injury and in those limited by mild soft-tissue injury.     

Exercise after surgical repair of congenital cardiac lesions

Congenital heart defects arise in approximately 1% of all live births, independent of ethnic and geographical considerations. With the development of new surgical procedures and current technologies a large number of these heart lesions can be surgically corrected in infancy. In the majority of cases patients evaluated some 10 to 20 years after surgery are asymptomatic and can lead a normal life. Despite their satisfactory clinical outcome patients may, nevertheless, show an abnormal pattern of physiological responses when submitted to dynamic exercise. This paper reviews the scientific literature concerning the exercise capabilities and the cardiorespiratory adjustments to exercise in patients surgically corrected for 4 of the most common congenital heart lesions: isolated atrial septal defect, isolated ventricular septal defects, pulmonary stenosis and tetralogy of Fallot. The maximal exercise tolerance of postoperative congenital heart defect patients may usually be related to: (a) the age of the patients at the time of surgery; (b) the severity of the lesions remaining after surgery; and (c) the age of the patients at the time of investigation. Although normal maximal exercise capabilities may be found in a good number of patients operated for either of the 4 lesions considered, this does not imply normal exercise haemodynamics. A general observation made in these 4 groups of patients is that of a subnormal exercise cardiac output which may or may not be fully compensated by an increase in peripheral oxygen extraction. The limitation in exercising cardiac output may, in turn, be attributed to either a subnormal stroke volume or a limitation in the chronotropic response to exercise or a combination of both factors. Residual pulmonary stenosis, increased pulmonary vascular resistance, increased myocardial stiffness are all factors that may contribute to the cardiac output limitation. A thorough explanation of underlying causes for the abnormal haemodynamic response to exercise, however, still remains to be provided.     

Diagnosis of bronchiolitis obliterans in heart-lung transplantation patients: importance of bronchial dilatation on CT.

OBJECTIVE. The purpose of this study was to evaluate the significance of bronchial dilatation identified on high-resolution CT scans obtained after heart-lung transplantation. Bronchial dilatation has been identified on pathologic specimens and on high-resolution CT scans of patients with severe bronchiolitis obliterans after lung transplantation, but this finding has not previously been systematically studied as a manifestation of this complication. MATERIALS AND METHODS. We studied the high-resolution CT scans of 16 patients who had had heart and lung transplantation at least 1 year before, and compared the percentage of dilated bronchi with evidence of small airways disease shown on pulmonary function tests. RESULTS. We found a close correlation between the percentage of bronchi in the lower lobes that were dilated and the percent predicted forced expiratory volume in 1 sec, forced vital capacity, and forced expiratory flow between 25% and 75% of vital capacity. No other feature identified on high-resolution CT scans correlated with pulmonary function abnormalities. CONCLUSION. We conclude that dilatation of the lower lobe bronchi is a good indicator of bronchiolitis obliterans in this population, and that the percentage of dilated bronchi generally increases with increasing pulmonary dysfunction.     

Heart-lung transplantation

Since the successful clinical reintroduction of heart and lung transplantation in 1981, more than 350 of these procedures have been performed worldwide. Although survival following this operation is less than that reported for heart transplantation, the results are improving. It is clear that the increased technical difficulty of the procedure combined with the exquisite susceptibility of the transplanted lung to postoperative injury from infection, rejection or other causes account for these differences. In this report we provide an overview of the experience in heart-lung transplantation and discuss recent advances. The late complication of chronic obliterative bronchiolitis, which may progress inexorably, has cast a shadow over the potential long-term success of this therapeutic procedure. Current research efforts are directed toward the cause, diagnosis, and treatment of this complication.     

Transverse folds in the human esophagus

Fine transverse folds can be seen by double contrast technique in the human esophagus which are similar to those seen regularly in the feline esophagus. These folds are transient in nature and possibly represent contraction of the muscularis mucosae. This fold pattern can be seen in patients with gastroesophageal reflux and in those with no symptoms of esophageal disease. The marginal serration should not be mistaken for diffuse ulceration on barium filled views of the esophagus. Distortion of interruption of the normal fold pattern can be seen in patients with superficial ulceration due to reflux esophagitis or other invasive mucosal lesions. Although the pathophysiologic significance of this phenomenon is uncertain, the demonstration and recognition of these folds allows for better definition of mucosal surface abnormalities.     

Yttrium-90 Radioembolization as a Bridge to Liver Transplantation: A Single-Institution Experience

PurposeTo evaluate our experience with the use of yttrium-90 (⁹⁰Y) radioembolization in maintaining potential candidacy and, in some instances, downstaging hepatocellular carcinoma (HCC) that does not meet Milan criteria for liver transplantation.Materials and MethodsA retrospective review of 20 consecutive patients with HCC who were listed to receive a liver transplant and were treated with ⁹⁰Y radioembolization as a sole modality for locoregional “bridge” therapy was performed. Demographics, radiographic and pathologic response, survival, and recurrences were examined.ResultsTwenty-two ⁹⁰Y treatments were performed in 20 patients before transplantation. Median time from first treatment to transplantation was 3.5 months. HCC in 14 patients met the Milan criteria at the time of the first ⁹⁰Y treatment, and HCC in six did not. All cases that originally met the Milan criteria remained within the criteria before transplantation, and two of six patients whose disease did not meet the criteria (33%) had their disease successfully downstaged to meet the criteria. Overall, nine patients (45%) had complete or partial radiologic response to ⁹⁰Y radioembolization according to modified Response Evaluation Criteria In Solid Tumors. Complete necrosis of tumor with no evidence of viable tumor on pathologic examination was observed in five patients (36%) whose disease met the Milan criteria.ConclusionsParticularly in regions with long wait list times, ⁹⁰Y treatment is effective in maintaining tumor size in potential liver transplantation candidates with HCC. In addition, it can also be considered as a downstaging therapy in select patients before transplantation.     

Interruption or congenital stenosis of the inferior vena cava: prevalence, imaging, and clinical findings

OBJECTIVE: To present the prevalence, clinical, and imaging findings of interruption or congenital stenotic lesions of the inferior vena cava (IVC), associated malformations, and their clinical relevance. MATERIALS AND METHODS: Between March 2004 and March 2006, 7972 patients who had undergone consecutive routine abdominal multidetector row computed tomography were analyzed for interruption or stenotic lesion of the IVC. RESULTS: Prevalence of interruption (n=8) or congenital stenosis (n=4) of the IVC occurred in 12 (0.15%) of 7972 patients. Four patients with interruption and four patients with congenital stenosis of the IVC were symptomatic with DVT (n=4), leg swelling (n=4), leg pain (n=2), lower extremity varices (n=2), hepatic vein thrombosis (n=1), and hematochezia (n=1). All four of the asymptomatic patients were from the interruption group, and these patients had interrupted IVC with well-developed azygos/hemiazygos continuation. Eight symptomatic patients did not have a well-developed azygos/hemiazygos continuation, and drainage of lower extremity was mainly from collateral veins. Additional findings in eight symptomatic patients were abdominal venous collaterals (n=8), venous aneurysm (n=2), lower extremity varices (n=2), varicocele (n=2), and pelvic varices (n=1). CONCLUSION: Interruption or stenosis of the IVC are rare on routine abdominal CT examinations and may cause different clinical findings depending on the variant drainage patterns or collaterals. Interrupted IVC is commonly asymptomatic if associated with well-developed azygos/hemiazygos continuation, whereas commonly symptomatic if well-developed azygos/hemiazygos continuation is not present.