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Nonischemic cardiomyopathies encompass a broad spectrum of myocardial disorders with mechanical or electrical dysfunction without evidence of ischemia. There are five broad variants of nonischemic cardiomyopathies; hypertrophic cardiomyopathy (Variant 1), restrictive or infiltrative cardiomyopathy (Variant 2), dilated or unclassified cardiomyopathy (Variant 3), arrhythmogenic cardiomyopathy (Variant 4), and inflammatory cardiomyopathy (Variant 5). For variants 1, 3, and 4, resting transthoracic echocardiography, MRI heart function and morphology without and with contrast, and MRI heart function and morphology without contrast are the usually appropriate imaging modalities. For variants 2 and 5, resting transthoracic echocardiography and MRI heart function and morphology without and with contrast are the usually appropriate imaging modalities. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

AIM To investigate the use of ultrasound (US)-guided biopsy of thoracic lesions aiming to determine diagnostic success and complication rates and to identify factors that may affect sample adequacy and safety. MATERIAL AND METHODS This was a retrospective study of consecutive percutaneous US-guided biopsy over 10-year period, including 147 procedures in 146 patients (66 ± 7 years, 83 men, 63 women) with lesions located in the lung (67/147), chest wall (54/147), mediastinum (14/147) and pleura (12/147). Overall diagnostic success, yield for benign and malignant diagnoses and diagnostic success according to lesion location, biopsy type (fine-need aspiration [FNA] or core-needle biopsy [CNB]) and number of specimens were calculated. Presence of complications and effect of age, lesion location, biopsy type, and number of specimens were measured. RESULTS The overall diagnostic success rate was 90.5% and was similar for malignant (90.6%) and benign (87.5%) diagnoses. Specimen adequacy was similar for FNA and CNB (91.2% and 88.9%, p=0.66); number of specimens did not affect yield. Diagnostic success was highest for mediastinal and chest wall lesions (92.9% and 94.4%) and lowest for pleural lesions (75%), albeit not statistically significant (p=0.45). Complications occurred in 4/147(2.7%) cases, exclusively in lung lesions, and were not associated with any covariates analysed. CONCLUSIONS US-guided biopsy is an effective and safe technique for diagnosis of thoracic lesions, with high diagnostic yield and low complication rate. In the presence of an adequate acoustic window, US guidance can be valuable for diagnosis of peripheral lung and mediastinal lesions. Radiologists performing thoracic biopsy should be encouraged to implement or expand the use of US guidance in their practice.

Cardiac sarcoidosis (CS) is an increasingly recognized condition, but cardiac magnetic resonance (CMR) image interpretation in these patients may be challenging as findings are often non-specific. The main objective of this study was to investigate the inter-reader agreement for the overall interpretation of CMR for the diagnosis of CS in an experienced reference center and investigate factors that may lead to discrepancies between readers. Consecutive patients undergoing CMR imaging to investigate for CS were included. CMR images were independently reviewed by two readers, blinded to all clinical, imaging and demographic information. The readers classified each scan as "consistent with cardiac sarcoidosis", "not consistent with cardiac sarcoidosis" or "indeterminate". Inter-reader agreement was assessed using κ-statistics. When there was disagreement on the overall interpretation, a third reader reviewed the images. Also, two readers independently commented on the presence of edema, presence of LGE (both ventricles) and quantified the extent of left ventricular LGE. 87 patients (43 women, mean age 54.3 ± 12.2 years) were included in the study. There was agreement regarding the overall interpretation in 72 of 87 (83%) CMR scans. The κ value was 0.64, indicating moderate agreement. There was similar moderate agreement in the interpretation of LGE parameters. In an experienced referral center, we found moderate agreement between readers in the interpretation of CMR in patients with suspected CS. Physicians should be aware of this inter-observer variability in interpretation of CMR studies in patients with suspected CS.

Background While an assessment of the right ventricular (RV) size remains challenging, the entire RV is can be imaged on coronary computed tomography angiography (CCTA) studies. With prospective ECG-triggering, the RV end diastolic volume (RVEDV) cannot be measured; however, the RV mid-diastolic volume (RVMDV) can still be measured accurately from routine CCTA data sets. The objective of this study is to establish normal reference values for RVMDV. Methods Right ventricular mid-diastolic volumes were measured in 4855 consecutive patients undergoing prospectively ECG-triggered coronary CTA. All patients with known cardiac or pulmonary disease (coronary artery disease, myocardial infarction, revascularization, heart failure, pulmonary hypertension, congenital heart disease, valvular heart disease, atrial fibrillation, implantable cardiac defibrillator implantation, cardiac transplant, or cardiac surgery) or smoking history (3313 patients) were excluded. Results 1542 patients were analyzed (mean age 56.4 ± 11.1 years, mean BSA 1.96 ± 0.26 and 47% male). The mean RVMDV for men and women was 168.6 ± 37.6 mL and 117.6 ± 26.4 mL, respectively. Mean BSA-indexed RVMDV was 80.0 ± 15.3 mL/m2 and 64.1 ± 12.2 mL/m2 for men and women, respectively. The presence of hypertension and diabetes did not have an impact on these values. RVMDV and BSA-indexed RVMDV were lower in women and in older individuals. Conclusion Normal reference ranges for RVMDV were established using prospectively ECG-triggered coronary CTA studies. This data can be used to identify patients with abnormal RV volumes and potentially RV dysfunction, adding incremental diagnostic value to routine CCTA studies.

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

BACKGROUND Left ventricular mass (LVM) is a predictor for adverse cardiovascular outcomes. Coronary atherosclerosis (coronary artery disease [CAD]) and concentric left ventricular (LV) remodeling are linked pathophysiologically by endothelial dysfunction. AIM This study sought to determine the potential association between coronary atherosclerosis and LVM. METHODS A total of 2384 consecutive patients, without structural heart disease or a medical history of CAD, undergoing prospective mid-diastolic electrocardiogram-gated computed tomography coronary angiography were enrolled in the study. LVM and LV mid-diastolic volume were measured using semiautomated software and indexed to body surface area. The average LV mid-diastolic wall thickness and concentricity index (LVM/LV mid-diastolic volume) were calculated. According to the Agatston Score, the patients were divided into 3 groups (Agatston=0, 0.1 to 399.9, ≥400). Similarly, patients were also divided into 4 groups on the basis of the Total Plaque Score (TPS) (0, 1 to 4, 5 to 8, and ≥9). In addition, patients were categorized according to CAD (normal coronaries, nonobstructive CAD, and obstructive stenosis [obstruction >50%]). The association between the different categories of CAD and LV measures was assessed. RESULTS Both left ventricular mass index (LVMi) and the LV concentricity index increased with TPS categories from 55.3±12.1, 57.4±11.7, 60.9±13.6, and 63.7±15.3 g/m2 (P

Low-attenuation plaques (LAPs) are associated with an increased risk of cardiovascular mortality and morbidity. South Asians experience poorer cardiovascular outcomes compared to Caucasian populations. We hypothesised that South Asian population has a higher prevalence of LAP compared to Caucasians and this difference predicts major adverse cardiovascular events. 72 Caucasian and 72 Morise score-matched South Asian patients were identified from a cardiac computed tomography angiography (CCTA) registry. Coronary artery plaque subtypes in proximal major epicardial and left main arteries were analysed from CCTA images using pre-determined attenuation ranges in Hounsfield units (HUs): 1 to 30 HU (low attenuation), 31 to 70 HU (intermediate attenuation), 71 to 150 HU (high attenuation), and mean coronary lumen + 2 standard deviations to 1000 HU (calcified). For each analysis, data comparison was performed for plaque volumes after normalising for the corresponding coronary artery outer vessel wall volume. The baseline characteristics and total plaque score of the two cohorts were similar. There were no statistically significant differences in low, intermediate, and high- attenuation, or calcified normalised plaque volumes between Caucasian and Morise score-matched South Asian cohorts. After a mean follow up of 32 months, major adverse cardiovascular events were similar between Caucasians and South Asians. In a Morise score-matched ethnicity study, we found no significant differences in plaque subtypes including LAP in South Asians compared to a Caucasian cohort. Other factors accounting for poor outcomes in South Asians should be investigated.

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background Obesity is an in independent risk factor for cardiovascular disease. Goal To describe the early LV remodelling pattern in patients with overweight and obesity and structurally normal hearts. Methods Consecutive patients (n = 2374), with structurally normal hearts and BMI ≥ 18.5 kg/m2, undergoing prospective mid-diastolic ECG gated CTCA were selected. Left ventricular mass (LVM) and Left ventricular mid-diastolic volume (LVMDV) were measured. The concentricity index (LVM/LVMDV) were calculated. According to the definitions of the World Health Organization (WHO), the patients were divided into weight categories. Results The mean LVM ± Std. deviation in the subgroups according to WHO classification was 101.68 ± 28.99 g (normal weight), 115.79 ± 29.14 g (overweight), 123.8 ± 33.44 g (class I obesity), 125.85 ± 32.89 g (class II obesity) and 132.45 ± 37.85 g (class III obesity). (p The mean LVMDV progressed with increasing WHO weight category from 112.37 ± 36.46 in patients with normal BMI to 140.26 ± 43.78 in patients with class III obesity. (p The concentricity index was 0.935 ± 0.216 g/ml in patients with normal BMI, 0.979 ± 0.253 g/ml, 1.058 ± 0.635 g/ml, 0.996 ± 0.284 g/ml and 0.9768 ± 0.244 g/ml in patients with BMI categories 25–29.99, 30–34.99, 35–39.99 and ≥40 kg/m2, respectively. Conclusions Our study demonstrates a non-linear (inverse U-shape) relationship between increasing BMI class and concentricity index, reaching its maximum at a BMI of 30–34.99 kg/m2. Further increase in BMI results in LV dilation.

Chronic chest pain (CCP) of a cardiac etiology is a common clinical problem. The diagnosis and classification of the case of chest pain has rapidly evolved providing the clinician with multiple cardiac imaging strategies. Though scintigraphy and rest echocardiography remain as appropriate imaging tools in the diagnostic evaluation, new technology is available. Current evidence supports the use of alternative imaging tests such as coronary computed tomography angiography (CCTA), cardiac MRI (CMRI), or Rb-82 PET/CT. Since multiple imaging modalities are available to the clinician, the most appropriate noninvasive imaging strategy will be based upon the patient's clinical presentation and clinical status. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

While there is no single diagnostic test for heart failure (HF), imaging plays a supportive role beginning with confirmation of HF, especially by detecting ventricular dysfunction ( Variant 1 ). Ejection fraction (EF) is important in HF classification, and imaging plays a subsequent role in differentiation between HF with reduced EF (HFrEF) versus preserved EF (HFpEF) ( Variant 2 ). Once HFrEF is identified, distinction between ischemic and nonischemic etiologies with imaging support ( Variant 3 ) facilitates further planning. Imaging approaches which are usually appropriate include: both resting transthoracic echocardiography (TTE) and chest radiography for Variant 1 ; resting TTE and/or MRI (including functional, without absolute need for contrast) for Variant 2 ; and for Variant 3 , a. Coronary CTA or coronary arteriography (if high pretest probability/symptoms for ischemic disease) for coronary assessment; b. Rest/vasodilator stress SPECT/CT, PET/CT, or MRI for myocardial perfusion assessment; c. Rest/exercise or inotropic stress TTE for myocardial contraction assessment; or d. MRI (including morphologic with contrast) for myocardial characterization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background: The identification of coronary artery calcification (CAC) detected coincidentally on chest CT exams could assist in cardiovascular risk assessment but may not be reported consistently on clinical studies. Cardiovascular risk factor stratification is important to predict short term cardiac events during cancer therapy and long term cardiac event free survival in cancer patients. We sought to determine the prevalence of CAC and clinical reporting rates in a cohort of cancer patients at high risk of cancer therapy related cardiac events. Methods: 408 Breast cancer patients who were referred to a cardiac oncology clinic were screened. Inclusion criteria included having had a CT chest and the absence of known coronary disease. Among those screened 263 patients were included in the study. Results: CAC was identified in 70 patients (26%). CAC was reported in 18% of studies. The reporting rates of CAC increased with the extent of coronary calcification (p

Rationale and Objectives The study aimed to identify a radiomic approach based on CT and or magnetic resonance (MR) features (shape and texture) that may help differentiate benign versus malignant pleural lesions, and to assess if the radiomic model may improve confidence and accuracy of radiologists with different subspecialty backgrounds. Materials and Methods Twenty-nine patients with pleural lesions studied on both contrast-enhanced CT and MR imaging were reviewed retrospectively. Three texture and three shape features were extracted. Combinations of features were used to generate logistic regression models using histopathology as outcome. Two thoracic and two abdominal radiologists evaluated their degree of confidence in malignancy. Diagnostic accuracy of radiologists was determined using contingency tables. Cohen's kappa coefficient was used to assess inter-reader agreement. Using optimal threshold criteria, sensitivity, specificity, and accuracy of each feature and combination of features were obtained and compared to the accuracy and confidence of radiologists. Results The CT model that best discriminated malignant from benign lesions revealed an AUC CT = 0.92 ± 0.05 ( P MR = 0.87 ± 0.09 ( P P P = 0.02). The most discriminative MR model was more accurate than one abdominal ( P = 0.04) and one thoracic radiologist ( P = 0.02). Conclusion Quantitative textural and shape analysis may help distinguish malignant from benign lesions. A radiomics-based approach may increase diagnostic confidence of abdominal radiologists on CT and MR and may potentially improve radiologists' accuracy in the assessment of pleural lesions characterized by MR.

BACKGROUND There is conflicting data on early left ventricle (LV) remodeling in diabetes mellitus (DM) and hypertension (HTN). This study examines the feasibility of cardiac computed tomography angiography (CCTA) to detect early LV geometric changes in patients with DM and HTN. METHODS Consecutive patients (n = 5,992) who underwent prospective electrocardiography (ECG)-triggered (mid-diastolic) CCTA were screened. Patients with known structural heart disease or known LV dysfunction were excluded. Left ventricular mass (LVM), left ventricular mid-diastolic volume (LVMDV), and LV concentricity (LVM/LVMDV) were measured and indexed to body surface area. RESULTS A total of 4,283 patients were analyzed (mean age 57 ± 10.69 years, female 46.7%). DM, HTN, and HTN + DM were present in 4.1%, 35.8% and 10.6% of patients, respectively. Compared to normal patients, HTN and HTN + DM patients had increased LVM indexed to body surface area (LVMi) (56.87 ± 17.24, 59.26 ± 13.62, and 58.56 ± 13.09, respectively; P < 0.05). There was no difference in LVMi between normal subjects and patients with DM (56.39 ± 11.50, P = 0.617). Concentricity indices were higher in patient with HTN (1.0456 ± 0.417; P < 0.001), DM (1.109 ± 0.638; P = 0.004), and HTN + DM (1.083 ± 0.311, P < 0.001) than normal individuals (0.9671 ± 0.361). There was no overlap of the 95% confidence intervals in the composite of concentricity indices and LVMi between the different groups. CONCLUSIONS CCTA measures of LVM and concentricity index may discriminate patients with HTN and DM before overt structural heart disease.

Objective Percutaneous biopsy of lung nodules is established as a safe procedure with high diagnostic yield and accuracy. Its role in the diagnosis of subcentimeter nodules is, however, less clear. The goal of this study was to evaluate diagnostic yield, accuracy, and safety of computed tomography (CT)-guided needle biopsy in the diagnosis of subcentimeter lung nodules. Material and methods A retrospective review of a prospectively maintained database over a 12-year period identified 133 eligible CT-guided needle biopsies of lesions ≤1 cm. Diagnostic yield and accuracy for the diagnosis of malignancy were calculated. Lesion features and procedure characteristics were assessed using univariate and multivariate logistic regression analysis to identify risk factors associated with biopsy failure and complications. Results Biopsy specimens were adequate for diagnosis in 116/133(87%) cases; the diagnostic yield for malignant and benign lesions was 93% and 65%, respectively. Final benign diagnosis was the strongest independent risk factor for biopsy failure. In multivariate logistic regression, fine-needle aspiration was an independent risk factor for diagnostic failure. Core needle biopsy was an independent risk factor for pneumothorax, and core needle biopsy, number of passes, and age were independent risk factors for pneumothorax requiring tube drainage. Conclusions CT-guided percutaneous needle biopsy had high diagnostic yield for the diagnosis of subcentimeter lung nodules with a similar complication rate to biopsy of larger lesions. Fine-needle aspiration may be an independent factor for diagnostic failure even for malignant lesions.

Aims Cardiac magnetic resonance (CMR) was used to assess whether cardiac function or tissue composition was affected in patients with well-functioning metal-on-metal hip resurfacing arthroplasties (MoMHRA) when compared with a group of controls, and to assess if metal ion levels correlated with any of the functional or structural parameters studied. Patients and Methods In all, 30 participants with no significant cardiac history were enrolled: 20 patients with well-functioning MoMHRA at mean follow-up of 8.3 years post-procedure (ten unilateral, ten bilateral; 17 men, three women) and a case-matched control group of ten non-MoM total hip arthroplasty patients (six men, four women). The mean age of the whole cohort (study group and controls) at the time of surgery was 50.6 years (41.0 to 64.0). Serum levels of cobalt and chromium were measured, and all patients underwent CMR imaging, including cine, T2* measurements, T1 and T2 mapping, late gadolinium enhancement, and strain measurements. Results None of the MoMHRA patients showed clinically significant cardiac functional abnormality. The MoMHRA patients had larger indexed right and left end diastolic volumes (left ventricular (LV): 74 ml/m2 vs 67 ml/m2, p = 0.045; right ventricular: 80 ml/m2 vs 71 ml/m2, p = 0.02). There was a small decrease in T2 time in the MoMHRA patients (median 49 ms vs 54 ms; p = 0.0003). Higher metal ion levels were associated with larger LV volumes and with shorter T2 time. Conclusion Although cardiac function is not clinically adversely affected in patients with well-functioning MoMHRA, modern imaging is able to demonstrate subtle changes in structure and function of the heart. As these changes correlate with systemic ion measurements, they may be consequences of wear debris deposition. Longer, longitudinal studies are necessary to determine whether cardiac function will become affected. Cite this article: Bone Joint J 2019;101-B:540–546.

The optimal assessment of patients with chest pain and possible acute coronary syndrome (ACS) remains a diagnostic dilemma for emergency physicians. Cardiac computed tomographic angiography (CCTA) may identify patients who can be safely discharged home from the emergency department (ED). The objective of the study was to compare the efficiency and safety of CCTA to standard care in patients presenting to the ED with low- to intermediate-risk chest pain. This was a single-center before-after study enrolling ED patients with chest pain and low to intermediate risk of ACS, before and after implementing a cardiac CT-based management protocol. The primary outcome was efficiency (time to diagnosis). Secondary outcomes included safety (30-day incidence of major adverse cardiovascular events (MACE)) and length of stay in the ED. We enrolled 258 patients: 130 in the standard care group and 128 in the cardiac CT-based management group. The cardiac CT group had a shorter time to diagnosis of 7.1 h (IQR 5.8-14.0) compared to 532.9 h (IQR 312.8-960.5) for the standard care group (p

While there is no single diagnostic test for heart failure (HF), imaging plays a supportive role beginning with confirmation of HF, especially by detecting ventricular dysfunction (Variant 1). Ejection fraction (EF) is important in HF classification, and imaging plays a subsequent role in differentiation between HF with reduced EF (HFrEF) versus preserved EF (HFpEF) (Variant 2). Once HFrEF is identified, distinction between ischemic and nonischemic etiologies with imaging support (Variant 3) facilitates further planning. Imaging approaches which are usually appropriate include: both resting transthoracic echocardiography (TTE) and chest radiography for Variant 1; resting TTE and/or MRI (including functional, without absolute need for contrast) for Variant 2; and for Variant 3, a. Coronary CTA or coronary arteriography (if high pretest probability/symptoms for ischemic disease) for coronary assessment; b. Rest/vasodilator stress SPECT/CT, PET/CT, or MRI for myocardial perfusion assessment; c. Rest/exercise or inotropic stress TTE for myocardial contraction assessment; or d. MRI (including morphologic with contrast) for myocardial characterization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Chronic chest pain (CCP) of a cardiac etiology is a common clinical problem. The diagnosis and classification of the case of chest pain has rapidly evolved providing the clinician with multiple cardiac imaging strategies. Though scintigraphy and rest echocardiography remain as appropriate imaging tools in the diagnostic evaluation, new technology is available. Current evidence supports the use of alternative imaging tests such as coronary computed tomography angiography (CCTA), cardiac MRI (CMRI), or Rb-82 PET/CT. Since multiple imaging modalities are available to the clinician, the most appropriate noninvasive imaging strategy will be based upon the patient's clinical presentation and clinical status. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cardiac computed tomography angiography (CCTA) is a noninvasive imaging technique that has been rapidly adopted into clinical practice. Over the past decade, technological advances have improved CCTA accuracy, and there is an increasing amount of data supporting its prognostic value in the assessment of coronary artery disease. Recently, "appropriate use criteria" has been used as a tool to minimize inappropriate testing and reduce patient exposure to unnecessary risk and inconclusive studies. This review will summarize the appropriate uses of CCTA in patients before and after cardiac surgery. Although the most common indication for CCTA is assessment of patency of native coronary arteries, other potential perioperative uses (eg, assessment of congenital heart disease, valvular heart disease, pericardial disease, myocardial disease, cardiac anatomy, bypass grafts, aortic disease, and cardiac masses) will be reviewed.

Background Coronary artery disease is a leading killer of women. Arterial stiffness predicts myocardial infarction, and postmenopausal women have lower arterial compliance ( AC ) than men. We hypothesized that lower AC would be associated with greater burden of coronary artery plaque and calcification, and that these associations would be stronger in women than men. Methods and Results We evaluated 3639 consecutive adults without coronary artery disease history who had coronary computed tomography between 2006 and 2014. Coronary artery calcification was calculated using the Agatston method. Plaque extent was assessed by the number of arterial segments with visible plaque divided by the number of visualized segments ×100 (percent plaque score). Indexed AC was calculated as stroke volume index/central pulse pressure. We used step‐wise multivariable linear regression to assess associations of log indexed AC with log (percent plaque score+1) and log (coronary artery calcification+1). Sex‐specific models were performed if the interaction sex× AC was significant. Mean age was 57±11 years, 53% were men, and 71% were hypertensive. Interaction term sex× AC was significant for both models ( P =0.008 for percent plaque score and 0.022 for coronary artery calcification). Lower indexed AC was associated with higher percent plaque score and coronary artery calcification in women (β± SE : −0.231±0.113, P =0.042 and −0.334±0.166, P =0.044, respectively), but not in men (β± SE : −0.062±0.104, P =0.551 and 0.114±0.173, P =0.510, respectively). Conclusions Lower AC is associated with greater burden of coronary artery plaque and calcification in women, but not in men. Our findings highlight low AC as a correlate of more‐advanced coronary artery disease and as a potential link to the worse cardiovascular outcomes in women.

PURPOSE: To generate normal reference values for left ventricular mid-diastolic wall thickness (LV-MDWT) measured by using CT angiography. MATERIALS AND METHODS: LV-MDWT was measured in 2383 consecutive patients, without structural heart disease, undergoing prospective electrocardiographically (ECG) triggered mid-diastolic coronary CT angiography. LV-MDWT was manually measured on automatically segmented short-axis images according to the American Heart Association’s 17-segment model. Commercially available automatic software was used to calculate the left ventricular (LV) mass. RESULTS: Among the 2383 patients, average LV-MDWT was 7.24 mm ± 1.86 (standard deviation [SD]), with the basal anteroseptal segment being the thickest wall (8.71 mm ± 2.19) and the apical inferior segment being the thinnest wall (5.9 mm ± 1.58; P < .001). Over all LV segments, the maximum upper limit, as defined as 2 SD above the mean, was 13.6 mm for men (LV1) and 11.2 mm for women. For men, only the basal anterior segment was above 13 mm. There was a significant difference in average LV-MDWT between women and men with 6.47 mm ± 1.07 and 7.90 mm ± 1.24, respectively (P < .001). Significant differences in LV-MDWT were found in the subgroups aged less than 65 years and greater than or equal to 65 years (P < .001). There was a strong correlation between LV-MDWT and LV mass (P < .001). CONCLUSION: Normal sex- and age-specific reference ranges for LV-MDWT in prospective ECG-triggered mid-diastolic coronary CT angiography have been provided. These benchmarks may expand the diagnostic and prognostic roles of CT angiography, beyond its role in the identification of coronary artery disease. © RSNA, 2019

Background Coronary computed tomography (CT) angiography (CCTA) has the ability to detect, characterize, and quantify atherosclerotic plaques. The aim of our study was to evaluate the prognostic power of CCTA-quantified plaque subtypes. Materials and methods A total of 36 patients with adverse events and 36 Morise score-matched patients who remained event free on follow-up were identified. Using CCTA images, plaque subtype volumes in the major epicardial arteries were analyzed using predetermined attenuation ranges in Hounsfield units (HU): 1 to 30 HU (low attenuating), 31 to 70 HU (intermediate attenuating), 71 to 150 HU (high attenuating), and mean coronary lumen+2 SD to 1000 HU (calcified). Each epicardial artery was divided into proximal, mid, and distal segments, and plaque volumes were normalized for arterial segment length. Results The baseline characteristics of the 2 cohorts were similar. Low-attenuation and intermediate-attenuation plaque volumes were greater in the proximal segments as well as in the entire length in the adverse event compared with the event-free group. High-attenuation plaque volume was increased only in the proximal segments in the adverse event group. There was no difference in the volume of calcified plaque between the 2 groups. The log rank test using a cutoff of 3.99 mm/mm for combined intermediate and low plaque volume showed more adverse events in patients with a plaque volume of ≥3.99 mm/mm. Conclusions Adverse events appear to be associated with greater volumes of low-attenuation and intermediate-attenuation plaques that reflect lipid and fibrous atherosclerosis. The difference between the 2 groups is most apparent in the proximal epicardial arteries.

Fat embolism syndrome (FES) is rare and diagnosis is challenging. Clinical manifestations are non-specific and no biochemical tests are reliable for diagnosis, highlighting the importance of thoracic CT. Our goal was to describe the CT manifestations of FES and assess whether imaging findings, time of onset of symptoms and time of surgery correlate with clinical course and severity of the disease.Retrospective review of 49 patients with respiratory distress after trauma/intramedullary nail fixation over a 10 year period; 12 patients met clinical criteria and were categorized as non-fulminant (NF-FES) or fulminant FES (F-FES). CT images were analyzed and electronic records reviewed for clinical findings, timeline from trauma to surgery and onset of symptoms. Pearson Chi-square and Levene's test were used and results considered significant when p0.05.All patients were men (18-80 years, mean 38 years), 5 (42%) suffered F-FES and 7 (58%) NF-FES. The most common CT finding was ground-glass opacities (8/12, 67%), often with lobular sparing. Consolidation occurred in 4/12 (33%), all in F-FES patients (p=0.004). In 5/5 F-FES, lung involvement was extensive (75%) whereas most NF-FES had limited involvement (p0.01). Centrilobular nodules were the predominant finding in 3/12 (16%). Median time between fracture and onset of symptoms was 43h, in 9/12 patients manifesting after surgery. Mean time between trauma and surgery was 20h in NF-FES and 52h in F-FES (p=0.02).The most common CT features of FES were ground-glass opacity and consolidation, less commonly, centrilobular nodules. The extent of ground-glass opacities and the presence of consolidation correlated with disease severity. Significant difference was found from time of trauma to surgery in the two groups however is uncertain whether delayed surgery truly increased the risk of F-FES.

To perform a systematic review to evaluate the diagnostic accuracy of hepatobiliary (HPB) phase gadoxetic acid-enhanced MR imaging of the liver in the diagnosis of focal nodular hyperplasia (FNH) versus hepatocellular adenoma (HCA) and to identify the rate of (a) reported HCAs that are iso- or hyperintense to liver and (b) reported FNHs that are hypointense to liver on HPB phase MR images.The institutional review board granted a waiver for this study type, and multiple databases were searched for studies in which researchers distinguished between FNH and HCA with gadoxetic acid-enhanced MR imaging. Studies to evaluate diagnostic accuracy were included; case reports and series were included to analyze the rate of iso- or hyperintense HCAs on HPB phase MR images. Risk of bias was assessed by using the Quality Assessment Tool for Diagnostic Accuracy Studies-2. Sensitivity and specificity were plotted with a forest plot; pooling was not performed because a small number of heterogeneous studies were included. Rate of iso- or hyperintense HCA on HPB phase gadoxetic acid-enhanced MR images was evaluated.Six studies (309 patients; 164 with HCA, 233 with FNH) were included for diagnostic accuracy assessment. Twelve case series (129 patients; 81 with HCA, 70 with FNH) were included (studies with insufficient 2 × 2 table data for diagnostic accuracy assessment). Sensitivity was high (range, 0.91-1.00; lower margin of the 95% confidence interval: 0.77). Specificity was high (range, 0.87-1.00; lower margin of the 95% confidence interval: 0.54). Specificity was lowest among studies in which molecular subtyping of HCA was performed. Rate of iso-or hyperintensity of HCA on HPB phase MR images was variable (range, 0%-67%) and occurred more frequently in the inflammatory subtype. High risk of bias was identified in the domains of patient selection and reference standard.The reported diagnostic accuracy of HPB phase gadoxetic acid-enhanced MR imaging in the diagnosis of HCA versus FNH is high; however, studies are few, heterogeneous, and at high risk for bias, indicating that diagnostic accuracy may be overestimated.

Background Fat embolism syndrome (FES) is a rare but potentially fatal complication of trauma or orthopedic surgery, which presents predominantly with pulmonary symptoms. Modern intensive care has improved the mortality rates, however diagnosis remains difficult, relying predominantly on a combination of a classic triad of symptoms and non-specific, but characteristic radiological features. The aim of this review is to describe the main clinical and imaging aspects of FES, ranging from pathophysiology to treatment with emphasis on pulmonary involvement. Methods We reviewed the currently published literature on the main characteristics of FES. Results In a hypoxic patient with recent trauma or orthopedic surgery, the presence of diffuse, well-demarcated ground glass opacities or ill-defined centrilobular nodules on computed tomography (CT) of the chest are suggestive of FES. Conclusions Combination of the classic clinical syndrome in the appropriate clinical setting, together with the characteristic imaging findings on chest CT, can help to achieve the correct diagnosis. Management remains predominantly supportive care, and the benefit of medical therapies such as corticosteroids and heparin remains unclear.

OBJECTIVE. The purposes of this article are to summarize the relevant literature on aerogenous metastasis, explain the putative pathogenetic mechanism of aerogenous spread, present the characteristic imaging and pathologic features, and review the importance of aerogenous spread to staging and clinical management. CONCLUSION. Cumulative evidence suggests that aerogenous spread may exist and is underrecognized. Imaging features are helpful in differentiating possible aerogenous spread of tumor from hematogenous and lymphatic metastases and from synchronous primary tumors. The putative occurrence of intrapulmonary aerogenous metastasis of lung cancer has staging, management, and prognostic implications.

Primary adenocarcinoma of lung has replaced squamous cell carcinoma as the commonest histological subtype of lung cancer and the incidence of primary lung adenocarcinoma appears to be rising. Although the main factors behind this 'epidemic-like' situation are largely undiscovered, filter cigarettes appear to significantly contribute to this shift in the histopathological spectrum. The new multidisciplinary classification of adenocarcinoma of lung was introduced to address advances in clinical, pathological, radiological and molecular sciences. The purpose of this essay is to discuss various classes of lung adenocarcinoma in the new classification with their classical imaging features on computed tomography and summarise the recent advances in the field of radiology and review radiology recommendations.