感染性心内膜炎的影像学评价

目的探讨超声心动图诊断感染性心内膜炎的价值。方法应用彩色超声多普勒诊断仪检查,常规行二维超声心动图及彩色多普勒血流显像检查,主要观察赘生物部位、大小、数目、活动度及瓣膜反流程度。结果 89例患者中,超声心动图均发现瓣膜赘生物形成,其中以主动脉瓣和二尖瓣受累为主;彩色多普勒显像瓣膜可有不同程度反流。结论超声心动图影像学技术对于心脏瓣膜赘生物引起的血流动力学变化和心功能改变、术前的决策以及预后均有重要意义。     

感染性心脏瓣膜心内膜炎的外科治疗

目的:总结感染性心脏瓣膜心内膜炎外科治疗的经验。方法:回顾性分析1998年6月～2007年6月成都军区总医院心外科手术治疗感染性心脏瓣膜心内膜炎38例。其中先天性心内畸形18例,风湿性心脏瓣膜病16例,原发性细菌性心内膜炎4例。术前22例行血液培养,阳性14例。术前心功能NYHA分级:Ⅱ级4例,Ⅲ级19例,Ⅳ级15例。行主动脉瓣置换11例,二尖瓣置换6例,主动脉瓣及二尖瓣置换18例,主动脉瓣、二尖瓣置换、三尖瓣置换3例,单纯心内分流修补8例,主动脉置换合并心内分流修补2例。术后应用足量敏感抗生素4～6w。结果:术后早期死亡3例,死因1例为多脏器栓塞后合并脑出血,1例心脏骤停,1例术后低心排。余术后心功能恢复NYHA分级Ⅰ～Ⅱ级33例,Ⅲ级2例。结论:感染性心脏瓣膜心内膜炎经外科治疗能够取得良好的治疗效果。     

Imaging of the neurological complications of infective endocarditis

We describe the findings on CT or MRI in five patients with neurological symptoms and underlying infective endocarditis (IE). We noted the size, number, and distribution of lesions, the presence or absence of haemorrhage, and contrast enhancement patterns. The number of lesions ranged from 4 to more than 10 in each patient. Their size varied from punctate to 6 cm; they were distributed throughout the brain. The lesions could be categorized into four patterns based on imaging features. A cortical infarct pattern was seen in all patients. Patchy lesions, which did not enhance, were found in the white matter or basal ganglia in three. Isolated, tiny, nodular or ring-enhancing white matter lesions were seen in three patients, and parenchymal haemorrhages in four. In addition to the occurrence of multiple lesions with various patterns in the same patient, isolated, tiny, enhancing lesions in the white matter seemed to be valuable features which could help to differentiate the neurological complications of IE from other thromboembolic infarcts. Received: 6 February 1997 Accepted: 19 June 1997     

多层螺旋CT冠状动脉成像质量控制

目的:探讨16层螺旋CT冠状动脉成像质量的影响因素.方法:82例患者行16层螺旋CT冠状动脉造影检查,评价不同心率、心动周期内不同R-R时相重建图像、不同注射方式的冠脉成像质量.结果:心率＜65次/min的55例患者中,有45例(81.8%)冠脉成像质量较优;心率≥65次/min的27例中仅10例(37%)冠脉重建图像较满意.两者间有明显的统计学显著性差异(P＜0.001).63例(76.8%)于心动周期的60%R-R间期重建图像质量最佳,仅10例(12.2%)于50%的R-R间期、9例(11%)于70%的R-R间期显示较佳.60%R-R间期分别与50%的R-R间期及70%的R-R间期重建图像间均有统计学显著性差异(P＜0.001).双相注射成像效果明显优于单相注射.结论:检查前控制好患者心率(＜65次/min)、选择最佳的重建时相窗(60% R-R间期)、双相注射对比剂等有利于提高冠脉的成像质量.     

The utility of cardiac MRI in diagnosis of infective endocarditis: preliminary results

PURPOSE

We aimed to evaluate the utility of cardiac magnetic resonance imaging (MRI) for the diagnosis of infective endocarditis (IE).

METHODS

Sixteen patients with a preliminary diagnosis of IE (10 women and six men; age range, 4–66 years) were referred for cardiac MRI. MRI sequences were as follows: echo-planar cine true fast imaging with steady-state precession (true-FISP), dark-blood fast spin echo T1-weighted imaging, T2-weighted imaging, dark-blood half-Fourier single shot turbo spin echo (HASTE), and early contrast-enhanced first-pass fast low-angle shot (FLASH). Delayed contrast-enhanced images were obtained using three-dimensional inversion recovery FLASH after 15±5 min. The MRI features were evaluated, including valvular pathologies on cine MRI and contrast enhancement on the walls of the cardiac chambers, major thoracic vasculature, and paravalvular tissue, attributable to endothelial extension of inflammation on contrast-enhanced images.

RESULTS

Fourteen valvular vegetations were detected in eleven patients on cardiac MRI. It was not possible to depict valvular vegetations in five patients. Vegetations were detected on the aortic valve (n=7), mitral valve (n=3), tricuspid and pulmonary valves (n=1). Delayed contrast enhancement attributable to extension of inflammation was observed on the aortic wall and aortic root (n=11), paravalvular tissue (n=4), mitral valve (n=2), walls of the cardiac chambers (n=6), interventricular septum (n=3), and wall of the pulmonary artery and superior mesenteric artery (n=1).

CONCLUSION

Valvular vegetation features of IE can be detected by MRI. Moreover, in the absence of vegetations, detection of delayed enhancement representing endothelial inflammation of the cardiovascular structures can contribute to the diagnosis and treatment planning of IE.The definition of infective endocarditis (IE) has now been expanded from infection of leaflets and chordae found in cardiac cavities, to infection of any structure in the heart, including the endothelial surface, valves, and myocardium, as well as prosthetic valves and implanted devices (1). Cardiac endothelium and valves are generally resistant to bacterial and fungal infection. However, some highly virulent microbial pathogens are capable of infecting normal cardiac valves (2). Animal studies suggest that the first stage of infection is endothelial damage, followed by deposition of platelet-fibrin, which sets the stage for bacterial colonization (3). Infection may also expand to the tissues surrounding the leaflets, including the sinotubular junction, annulus, myocardium, and the conduction system (1).There have been developments in treatment of IE, as well as prevention and detection of possible complications. Nevertheless, hospital mortality remains at the high rate of 20% (4). Despite advances in diagnostic methods, diagnosis is complicated as IE does not exhibit specific clinical signs in the early stage and has variable features (5). The diagnostic criteria for IE, known as the Duke criteria, were defined by Durack et al., in 1994 (6). These criteria have recently been expanded to include the use of transesophageal echocardiography and microbial antibody titers, and the proposed changes have been published and confirmed by other authors (1).While computed tomography (CT) and magnetic resonance imaging (MRI) are common modalities in diagnosis of stroke and embolic events, their functionality in cardiac pathology imaging is not entirely clear. Several studies report using MRI for diagnosis of IE (7–10), but no large series studies have been conducted to date.Diagnosis of IE by cross-sectional imaging has been restricted to depiction of valvular vegetations and other valvular pathologies. However, diagnosis of IE based on contrast enhancement pattern of the endothelial lining on MRI has not been previously studied. In the present study, in addition to the depiction of valvular pathologies on cine MRI, contrast enhancement pattern of the endothelial lining was evaluated by early and delayed contrast-enhanced images to contribute to the diagnosis of IE.     

Role of 18F-FDG PET/CT in the diagnosis of infective endocarditis in patients with an implanted cardiac device: a prospective study

Purpose

Infective endocarditis (IE) is widely underdiagnosed or diagnosed after a major delay. The diagnosis is currently based on the modified DUKE criteria, where the only validated imaging technique is echocardiography, and remains challenging especially in patients with an implantable cardiac device. The aim of this study was to assess the incremental diagnostic role of ¹⁸F-FDG PET/CT in patients with an implanted cardiac device and suspected IE.

Methods

We prospectively analysed 27 consecutive patients with an implantable device evaluated for suspected device-related IE between January 2011 and June 2013. The diagnostic probability of IE was defined at presentation according to the modified DUKE criteria. PET/CT was performed as soon as possible following the clinical suspicion of IE. Patients then underwent medical or surgical treatment based on the overall clinical evaluation. During follow-up, we considered: lead cultures in patients who underwent extraction, direct inspection and lead cultures in those who underwent surgery, and a clinical/instrumental reevaluation after at least 6 months in patients who received antimicrobial treatment or had an alternative diagnosis and were not treated for IE. After the follow-up period, the diagnosis was systematically reviewed by the multidisciplinary team using the modified DUKE criteria and considering the new findings.

Results

Among the ten patients with a positive PET/CT scan, seven received a final diagnosis of “definite IE”, one of “possible IE” and two of “IE rejected”. Among the 17 patients with a negative PET/CT scan, four were false-negative and received a final diagnosis of definite IE. These patients underwent PET/CT after having started antibiotic therapy (≥48 h) or had a technically suboptimal examination.

Conclusion

In patients with a cardiac device, PET/CT increases the diagnostic accuracy of the modified Duke criteria for IE, particularly in the subset of patients with possible IE in whom it may help the clinician manage a challenging situation.     

自发性腹腔干夹层的MSCT血管成像表现

【摘要】目的：总结自发性腹腔干夹层的MSCT血管成像表现。方法：回顾性分析14例自发性腹腔干夹层患者的临床及MSCT血管成像表现。结果：14例患者中自发性腹腔干夹层10例（71.4%,10/14）,腹腔干和肠系膜上动脉夹层4例（28.6%,4/14）。14条腹腔干血管和4条肠系膜上动脉夹层均显示了内膜片、破口及真假腔,3条血管夹层合并血栓,2条夹层血管合并钙化,2例患者合并周围血肿,1例合并脾梗死。14条腹腔干夹层中6条血管夹层伴有动脉瘤样突起,4条肠系膜上动脉夹层均伴有动脉瘤样突起。2例患者行DSA检查,DSA表现与MSCT血管成像表现一致,1例行支架植入术后复查见支架内血栓形成。结论：MSCT血管成像能敏感地显示腹腔干夹层的病理改变,可作为其诊断和随访的首选检查方法。     

Features of cardiac disease demonstrated on CT pulmonary angiography

The heart and mediastinal structures can be overlooked at CT pulmonary angiogram (CTPA). This pictorial review will demonstrate the features of cardiac disease that may be evident on a CTPA. CTPA allows assessment of not only the pulmonary arteries for embolism, but also of the bronchi, lung parenchyma, mediastinum and heart. Co-existent underlying or incidental cardiac disease is often present. Potentially life-threatening alternative diagnoses in a patient with chest symptoms can be reliably identified. Pathologies of the myocardium including hypertrophic cardio myopathy, pericardial disease, valvular disease, coronary artery disease, and intracardiac abnormalities are demonstrated pictorially. CTPA is increasingly used for the detection of pulmonary embolism. Most patients investigated have pathology other than PE as a cause of their symptoms. Frequently information about the heart is produced that provides important clues to determine the cause for the presenting symptoms and signs or reveals co-existing pathology. It is important to have a clear understanding of the features of cardiac disease which may be seen on a CTPA.     

Diagnosis of left ventricular pseudoaneurysm by cardiac CT angiography

We present a case of a patient with left ventricular pseudoaneurysm which was not noted on transthoracic echocardiography but incidentally detected by CT angiography in preparation of ablation therapy for ventricular tachycardia. The patient underwent successful surgical repair of the pseudoaneurysm. The case illustrates the utility of CT angiography for the diagnosis of this rare, but hazardous condition.     

Hemorrhagic brain abscess in infective endocarditis

We report a case of infective endocarditis (IE) that presented with acute neurological deterioration due to bleeding into a brain abscess disseminated from mitral valve vegetation. The patient recovered following surgical evacuation of hemorrhage/abscess and prolonged systemic administration of antibiotics. Although IE causes various neurological complications including intracranial hemorrhage, hemorrhagic brain abscess in patients with IE is rare. Appropriate combination of diagnostic modalities including computed tomography, magnetic resonance imaging, cardiac ultrasonography, and cerebral angiography, together with careful evaluation of the clinical history, leads to accurate diagnosis and treatment of patients with IE presenting with neurological complications.     

18F-FDG PET/CT for early detection of embolism and metastatic infection in patients with infective endocarditis

Purpose  

In the acute setting of endocarditis it is very important to assess both the vegetation itself, as well as potential life-threatening complications, in order to decide whether antibiotic therapy will be sufficient or urgent surgery is indicated. A single whole-body scan investigating inflammatory changes could be very helpful to achieve a swift and efficient assessment.     

A rare cause of delayed contrast enhancement on cardiac magnetic resonance imaging: infective endocarditis

Although there have been a few reports about the magnetic resonance (MR) imaging features of infective endocarditis (IE), delayed contrast enhancement attributable to fibrosis has not been previously described. The case of a 4-year-old girl who was diagnosed with IE based on positive blood culture results and echocardiographic findings is presented. At cardiac MR imaging, late phase contrast-enhanced images revealed a significant enhancement suggesting fibrosis secondary to IE.