Pulmonary Regurgitation: Determining Severity by Echocardiography and Magnetic Resonance Imaging

Objective. Pulmonary regurgitation (PR) is common after repair of congenital heart disease involving the right ventricular outflow tract. Because PR results in chronic right ventricular volume overload and associated morbidity and mortality, accurate assessment of its severity is important. The aim of this study was to compare echocardiography with the gold standard of PR quantitation by magnetic resonance imaging (MRI) in a young population with repaired congenital heart disease. Design/Methods. Patients with congenital heart disease who had undergone right ventricular outflow tract reconstruction and/or pulmonary valve replacement and had an MRI within 3 months of an echocardiogram formed the study group. Echocardiographic indices were compared with MRI‐determined pulmonary regurgitant fraction (PRF) to determine the most accurate measurements to quantitate PR. Results. Of the 69 MRI/echocardiography pairs in 64 patients, 53 data sets were complete and used in the analysis. For the prediction of MRI PRF ≥20%, PR jet width/annulus ratio ≥0.5 demonstrated excellent sensitivity (94%), specificity (100%), positive predictive value (PPV 100%), and negative predictive value (NPV 82%). For the prediction of MRI PRF ≥40%, jet width/annulus ratio ≥0.7 and diastolic flow reversal in the branch pulmonary arteries showed useful sensitivity (92%), specificity (68%), PPV (76%), and NPV (88%). Conclusion. Pulmonary regurgitation jet width/annulus ratio combined with diastolic flow reversal is the most valuable echocardiographic measure for assessing PR severity after right ventricular outflow tract reconstruction or pulmonary valve replacement; however, this surrogate measure does not replace the importance of MRI evaluation.     

Test-Retest Reliability of the Addiction Severity Index Composite Scores Among Clients in Residential Treatment

The authors investigated the test-retest reliability of the Addiction Severity Index (ASI) composite scores and the use of “free-living vs. institutionalized” reporting periods among 112 patients admitted to either of two residential, drug-free treatment programs in New England. Alcohol and drug scores were substantially lower for institutionalized vs. free-living reporting periods. Intraclass correlation coefficients were high (> 0.80) for the alcohol, drug, employment, and legal scores, but lower (0.50–0.59) for the psychiatric and medical scores and did not differ substantially by type of reporting period or by lag period between end of the reporting period and the interview. The use of free-living reporting periods yields more valid ASI scores for drugs and alcohol, in particular, and yields comparable reliability.     

Addictive Severity in Cocaine Addicts Measured with the EuropASI: Differences between Composite Scores and Severity Ratings

In this study we present the addiction severity profile in a sample of 202 cocaine addicts, using the composite scores for each area of the EuropASI (European version of the ASI), which are compared with the severity ratings obtained through interviewers' subjective assessments. The results showed that the areas of the EuropASI which reflected the greatest severity according to the composite scores were, in the following order: employment/support, family/social situation, use of alcohol and psychiatric state. The results obtained with the composite scores show discrepancies with those obtained from the severity rating. Statistically significant differences were found in the areas of alcohol (Z = ?6.205; p < 0.001), drugs (Z = ?11.902; p < 0.001), family/social (Z = ?6.915; p < 0.001) and psychiatric status (Z = ?6.651; p < 0.001). The results call into question the reliability and validity of severity ratings obtained through interviewers' subjective assessments. For diagnosis and research, a more objective appraisal is recommended, using composite scores, since severity ratings depend totally on the interviewer's judgement, and do not appear to constitute a sound measure for estimating therapeutic change.     

Quantification of Myocardial Area at Risk: Validation of Coronary Angiographic Scores With Cardiovascular Magnetic Resonance Methods

Introduction and objectives

Quantification of myocardial area-at-risk after acute myocardial infarction has major clinical implications and can be determined by cardiovascular magnetic resonance. The Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores have been widely used for rapid myocardial area-at-risk estimation but have not been directly validated. Our objective was to compare the myocardial area-at-risk estimated by BARI and APPROACH angiographic scores with those determined by cardiovascular magnetic resonance.

Methods

In a prospective study, cardiovascular magnetic resonance was performed in 70 patients with a first successfully-reperfused ST-segment elevation acute myocardial infarction in the first week after percutaneous coronary intervention. Myocardial area-at-risk was obtained both by analysis of T2-short tau inversion recovery sequences and calculation of infarct endocardial surface area with late enhancement sequences. These results were compared with those of BARI and APPROACH scores.

Results

BARI and APPROACH showed a statistically significant correlation with T2-short tau inversion recovery for myocardial area-at-risk estimation (BARI, intraclass correlation coefficient=0.72; P<.001; APPROACH, intraclass correlation coefficient=0.69; P<.001). Better correlations were observed for anterior acute myocardial infarction than for other locations (BARI, intraclass correlation coefficient=0.73 vs 0.63; APPROACH, intraclass correlation coefficient=0.68 vs 0.50). Infarct endocardial surface area showed a good correlation with both angiographic scores (BARI, intraclass correlation coefficient=0.72; P<.001; with APPROACH, intraclass correlation coefficient=0.70; P<.001).

Conclusions

BARI and APPROACH angiographic scores allow reliable estimation of myocardial area-at-risk in current clinical practice, particularly in anterior infarctions.     

Evaluation of the Severity of Mitral Regurgitation by the Use of Signal Void in Magnetic Resonance Imaging

Background: The study was designed to evaluate the severity of mitral regurgitation by cardiac magnetic resonance imaging (MRI). We proposed a new measurement of signal void by MRI and tried to define threshold values for the severity of regurgitation with different sequences. Methods: Twenty‐one patients with mitral regurgitation were evaluated by echocardiography and MRI. We measured the length, width, and the area of jet flow void from long‐axis and four‐chamber views. The regurgitant area was measured with TrueFISP, FLASH sequences, and phase images by tracing the signal‐void area in left atrium parallel to mitral annulus. This new parameter for grading of the severity of mitral regurgitation by cine MRI was called regurgitant area from short axis (RAFSA). Results: All methods (EROA, vena contracta) were correlated for determining the regurgitation severity (P < 0.01). There was a correlation between EROA by echocardiography and RAFSA by MRI with the TrueFISP, FLASH sequences, and phase images (P < 0.01). Stepwise regression analysis revealed that EROA was significantly correlated with RAFSA by phase images (P < 0.001). After regression analysis, threshold values of RAFSA by phase imaging were calculated and found to be 0.27 cm² and 0.92 cm² between mild, moderate, and severe mitral regurgitations (100% sensitivity, 67% specificity, and 100% sensitivity, 78% specificity, respectively) (P < 0.01, P < 0.05). Conclusions: MRI is an alternative method for evaluating mitral regurgitation. Our study suggests a new parameter, RAFSA by cine MRI, to grade the severity of mitral regurgitation and provides threshold values in order to define mild, moderate, and severe regurgitations. (ECHOCARDIOGRAPHY, Volume **, ***********)     

CASE REPORT: Usefulness of Magnetic Resonance Spectroscopy for Diagnosis of Hepatic Encephalopathy in a Patient with Relapsing Confusional Syndrome

Magnetic resonance spectroscopy allows the assessment of several metabolites in brain tissue. In patients with hepatic encephalopathy, this technique shows a rise in glutamine and a decrease in myoinositol in brain tissue. However, the role of magnetic resonance spectroscopy in the diagnosis of hepatic encephalopathy is not known. We report the case of a patient with a relapsing confusional syndrome who underwent magnetic resonance spectroscopy. Previously, hepatic encephalopathy was ruled out because of the negative results of a transjugular liver biopsy and normal hepatic venous pressure gradient. The results of magnetic resonance were characteristic of hepatic encephalopathy. Abdominal computed tomography demonstrated large portosystemic shunts associated with cirrhosis of the liver. This case shows that magnetic resonance spectroscopy is an useful technique for the diagnosis of hepatic encephalopathy in selected cases, such as those without clinical signs of cirrhosis and/or large portosystemic shunts.     

Prognostic Impact of Ischemic Mitral Regurgitation Severity and Myocardial Infarct Quantification by Cardiovascular Magnetic Resonance

ObjectivesThis study sought to evaluate the role of cardiac magnetic resonance (CMR) for the quantification of ischemic mitral regurgitation (IMR) and myocardial infarct size (MIS) in patients with ischemic cardiomyopathy (ICM). This study also sought to explore the interaction between IMR severity and MIS and its association with outcomes in patients with ICM.BackgroundIMR occurs secondary to a disease of the left ventricle and is associated with poor outcomes. The role of CMR for the evaluation and risk stratification of patients with ICM and IMR remains uncertain.MethodsConsecutive patients with ICM who underwent baseline CMR were included. MIS was quantified on late gadolinium enhancement imaging as the proportion of left ventricular mass. IMR was quantified with CMR by calculating the mitral regurgitant fraction (MRFraction). Cox proportional hazards models were built to assess the association of IMR and MIS quantification with the combined endpoint of all-cause death or heart transplant.ResultsWe evaluated 578 patients (mean age: 62 ± 11 years, 76% males). The mean left ventricular ejection fraction was 25 ± 11%, with an MIS of 24 ± 16% and MRFraction of 18 ± 17%. Over a median follow-up time of 4.9 years, 198 (34%) patients experienced death or cardiac transplant. On multivariable analysis, after comprehensive medical risk score, subsequent revascularization, implantable cardioverter-defibrillator insertion, and surgical mitral valve intervention were controlled for, the interaction of IMR severity and MIS emerged as a powerful predictor of adverse outcomes (p = 0.008). For patients with significant IMR (MRFraction: ≥35%), the hazard ratio comparing moderate MIS (15% to 29%) versus small MIS (<15%) was 1.51 (0.57 to 3.98), and the hazard ratio comparing large MIS (≥30%) versus small MIS was 5.41 (2.34 to 12.7).ConclusionsRisk associated with IMR is more comprehensively described as an interaction between IMR severity and MIS. Further studies in patients IMR using comprehensive CMR evaluation are needed to verify whether this approach can improve patient selection and procedural outcomes to address IMR.     

Usefulness of Magnetic Resonance Neurography for Diagnosis of Piriformis Muscle Syndrome and Verification of the Effect After Botulinum Toxin Type A Injection: Two Cases

Piriformis muscle syndrome (PMS) is a controversial neuromuscular disorder that is presumed to involve compression neuropathy of the sciatic nerve at the level of the piriformis muscle. Botulinum toxin A (BTX-A) injection into the piriformis muscle is widely used as a treatment aimed at relieving sciatic nerve compression.In 2 patients with PMS, magnetic resonance neurography (MRN) was taken before and after BTX-A injection. The first MRN was performed as a diagnostic tool, and the second to identify the effect of the treatment. Signal change of the sciatic nerve under the hypertrophied piriformis muscle was confirmed by MRN. In follow-up MRN performed after BTX-A injection into the piriformis muscle, changes of the sciatic nerve and piriformis muscle were noticed as well as improvement of clinical symptoms.MRN is a useful tool to add certainty of diagnosis and verify the effect of treatment in PMS.     

Effects of Abstinence on the Brain: Quantitative Magnetic Resonance Imaging and Magnetic Resonance Spectroscopic Imaging in Chronic Alcohol Abuse

Background: Structural brain damage, especially to white matter, is well documented in chronic alcohol abuse. There is also evidence for brain metabolic abnormalities in this condition. It is unknown, however, to what extent these structural and metabolic changes are present in treated alcohol abusers who achieve long-term abstinence versus treatment-naïve, heavily drinking individuals. Methods: This study compared 12 recovering alcoholics with 8 actively heavily drinking subjects. Participants underwent magnetic resonance (MR) imaging and proton MR spectroscopic imaging of the brain. Semiautomated image segmentation techniques yielded volumes for gray matter, white matter, white matter lesions, and cerebral spinal fluid in multiple brain regions defined by Talairach stereotaxic coordinates. Automated spectral processing methods yielded gray and white matter concentrations of the metabolites N-acetylaspartate, creatine, and choline for the same regions. Results: Recovering alcoholics had greater volumes of frontal white matter, but the opposite was true for white matter in a “remainder” region encompassing the basal frontal and temporal lobes, the cerebellum, and the brainstem. Recovering alcoholics also had smaller volumes of white matter lesions in whole brain, in occipital and mesial parietal regions, and in the remainder region. Recovering alcoholics had greater gray matter volumes in the orbital frontal pole and postcentral gyrus, but smaller gray matter volumes in the anterior cingulate. Whole-brain and regional metabolite concentrations did not differ significantly between the two groups. Conclusions: White and gray matter volumes in different regions of the brain were greater or smaller in recovering, treated alcoholics. The findings suggest region-specific structural recovery from chronic alcohol–induced brain injury, but also region-specific long-term structural damage in abstinent alcoholics. White matter lesions were widespread in active drinkers and may partly resolve during long-term abstinence. Proton MR spectroscopic measures, as applied in this cross-sectional study, were largely ineffective in revealing metabolic effects of abstinence on the alcohol-damaged brain.