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The complex pathobiology of lung cancer, and its spread worldwide, has prompted research studies that combine radiomic and genomic approaches. Indeed, the early identification of genetic alterations and driver mutations affecting the tumor is fundamental for correctly formulating the prognosis and therapeutic response. In this work, we propose a radiogenomic workflow to detect the presence of KRAS and EGFR mutations using radiomic features extracted from computed tomography images of patients affected by lung adenocarcinoma. To this aim, we investigated several feature selection algorithms to identify the most significant and uncorrelated sets of radiomic features and different classification models to reveal the mutational status. Then, we employed the SHAP (SHapley Additive exPlanations) technique to increase the understanding of the contribution given by specific radiomic features to the identification of the investigated mutations. Two cohorts of patients with lung adenocarcinoma were used for the study. The first one, obtained from the Cancer Imaging Archive (TCIA), consisted of 60 cases (25% EGFR, 23% KRAS); the second one, provided by the Azienda Ospedaliero-Universitaria ’Ospedali Riuniti’ of Foggia, was composed of 55 cases (16% EGFR, 28% KRAS). The best-performing models proposed in our study achieved an AUC of 0.69 and 0.82 on the validation set for predicting the mutational status of EGFR and KRAS, respectively. The Multi-layer Perceptron model emerged as the top-performing model for both oncogenes, in some cases outperforming the state of the art. This study showed that radiomic features can be associated with EGFR and KRAS mutational status in patients with lung adenocarcinoma.

Background Scar burden with late gadolinium enhancement (LGE) cardiac MRI (CMR) predicts arrhythmic events in patients with postinfarction in single-center studies. However, LGE analysis requires experienced human observers, is time consuming, and introduces variability. Purpose To test whether postinfarct scar with LGE CMR can be quantified fully automatically by machines and to compare the ability of LGE CMR scar analyzed by humans and machines to predict arrhythmic events. Materials and Methods This study is a retrospective analysis of the multicenter, multivendor CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry. Patients with chronic heart failure, echocardiographic left ventricular ejection fraction (LVEF) of less than 50%, and LGE CMR were recruited (from January 2015 through December 2020). In the current study, only patients with ischemic cardiomyopathy were included. Quantification of total, dense, and nondense scars was carried out by two experienced readers or a Ternaus network, trained and tested with LGE images of 515 and 246 patients, respectively. Univariable and multivariable Cox analyses were used to assess patient and cardiac characteristics associated with a major adverse cardiac event (MACE). Area under the receiver operating characteristic curve (AUC) was used to compare model performances. Results In 761 patients (mean age, 65 years ± 11, 671 men), 83 MACEs occurred. With use of the testing group, univariable Cox-analysis found New York Heart Association class, left ventricle volume and/or function parameters (by echocardiography or CMR), guideline criterion (LVEF of ≤35% and New York Heart Association class II or III), and LGE scar analyzed by humans or the machine-learning algorithm as predictors of MACE. Machine-based dense or total scar conferred incremental value over the guideline criterion for the association with MACE (AUC: 0.68 vs 0.63, P = .02 and AUC: 0.67 vs 0.63, P = .01, respectively). Modeling with competing risks yielded for dense and total scar (AUC: 0.67 vs 0.61, P = .01 and AUC: 0.66 vs 0.61, P = .005, respectively). Conclusion In this analysis of the multicenter CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry, fully automatic machine learning-based late gadolinium enhancement analysis reliably quantifies myocardial scar mass and improves the current prediction model that uses guideline-based risk criteria for implantable cardioverter defibrillator implantation. ClinicalTrials.gov registration no.: NCT03352648 Published under a CC BY 4.0 license. Supplemental material is available for this article. ispartof: Radiology vol:307 issue:3 pages:e222239- ispartof: location:United States status: published

Although children with Covid-19 generally present with mild symptoms or are often asymptomatic, there is increasing recognition of a delayed multi-organ inflammatory syndrome (MIS-C) following SARS-CoV-2 infection. We report the case of MIS-C associated arrhythmic myocarditis which recovered after anti-inflammatory therapy and immunoglobulin infusion.

Purpose: The Italian Registry of Contrast Material use in Cardiac Computed Tomography (iRCM-CCT) is a multicenter, multivendor, observational study on the use of contrast media (CM) in patients undergoing cardiac computed tomography (CCT). The aim of iRCM-CCT is to assess image quality and safety profile of intravenous CM compounds. Materials and methods: iRCM-CCT enrolled 1842 consecutive patients undergoing CCT (≥50 per site) at 20 cluster sites with the indication of suspected coronary artery disease. Demographic characteristics, CCT, and CM protocols, clinical indications, safety markers, radiation dose reports, qualitative (ie, poor vascular enhancement) and quantitative (ie, HU attenuation values) image parameters were recorded. A centralized coordinating center collected and assessed all image parameters. Results: The cohort included 891 men and 951 women (age: 63±14 y, body mass index: 26±4 kg/m2) studied with ≥64 detector rows computed tomography scanners and different iodinated intravenous CM protocols and compounds (iodixanol, iopamidol, iohexol, iobitridol, iopromide, and iomeprol). The following vascular attenuation was reported: 504±147 HU in the aorta, 451±146 HU in the right coronary artery, 474±146 HU in the left main, 451±146 HU in the left anterior descending artery, and 441±149 HU in the circumflex artery. In 4% of cases the image quality was not satisfactory due to poor enhancement. The following adverse reactions to CM were recorded: 6 (0.3%) extravasations and 17 (0.9%) reactions (11 mild, 4 moderate, 2 severe). Conclusions: In a multicenter registry on CM use during CCT the prevalence of CM-related adverse reactions was very low. The appropriate use of CM is a major determinant of image quality.

Hypertrophic cardiomyopathy (HCM) is a cardiac muscle disorder characterized by generally asymmetric abnormal hypertrophy of the left ventricle without abnormal loading conditions (such as hypertension or valvular heart disease) accounting for the left ventricular wall thickness or mass. The incidence of sudden cardiac death (SCD) in HCM patients is about 1% yearly in adults, but it is far higher in adolescence. HCM is the most frequent cause of death in athletes in the Unites States of America. HCM is an autosomal-dominant genetic cardiomyopathy, and mutations in the genes encoding sarcomeric proteins are identified in 30–60% of cases. The presence of this genetic mutation carries more than 2-fold increased risk for all outcomes, including ventricular arrhythmias. Genetic and myocardial substrate, including fibrosis and intraventricular dispersion of conduction, ventricular hypertrophy and microvascular ischemia, increased myofilament calcium sensitivity and abnormal calcium handling, all play a role as arrhythmogenic determinants. Cardiac imaging studies provide important information for risk stratification. Transthoracic echocardiography can be helpful to evaluate left ventricular (LV) wall thickness, LV outflow-tract gradient and left atrial size. Additionally, cardiac magnetic resonance can evaluate the prevalence of late gadolinium enhancement, which when higher than 15% of LV mass is a prognostic maker of SCD. Age, family history of SCD, syncope and non-sustained ventricular tachycardia at Holter ECG have also been validated as independent prognostic markers of SCD. Arrhythmic risk stratification in HCM requires careful evaluation of several clinical aspects. Symptoms combined with electrocardiogram, cardiac imaging tools and genetic counselling are the modern cornerstone for proper risk stratification.

Introduction: The immunosuppressive efficiency obtained in the last decades in kidney transplantation significantly improved graft survival. However, there is still a high risk and incidence of cancer in transplant patients strongly and directly related to the type of immunosuppression. An increasing body of evidence suggests that the PI3K/Akt/mTOR pathway may play a pivotal role in the development and progression of several neoplastic diseases. Case Presentation: We describe a 47-year-old male patient who received a cadaveric primary renal transplant in November 2008 developing a poorly differentiated infiltrating and ulcerated squamous cell carcinoma (SCC) at the eye level. In this patient, the modification of an immunosuppressive regimen with introduction of rapamycin (mTOR) inhibitors and withdrawal of calcineurin inhibitors (CNIs) led to the resolution of this severe condition. Conclusion: The introduction of mTOR inhibitors and withdrawal of CNIs in kidney-transplanted patients with de novo eye SCC should be considered in this clinical setting.

Outflow tract (OT) premature ventricular contractions (PVCs) are commonly found in clinical practice; in most cases, PVCs are benign and observed in structurally normal hearts, not requiring any therapeutic intervention. In this study, we therefore sought to evaluate with cardiac magnetic resonance (CMR) patients with PVC and apparently normal heart at echocardiographic examination, in order to identify possible substrates linked with higher prevalence of arrhythmias or structural heart disease. Thirty-three consecutive patients with frequent PVCs originating from the ventricular OT (right and left) were enrolled in the study and assessed by echocardiography and CMR. All patients had normal baseline electrocardiogram. CMR showed structural changes in 5 patients out of 33; in 3 cases, areas of fibrosis limited in one case to the middle basal segments of the interventricular septum and in two patients to the middle basal segments of the inferior-lateral wall were found. In 2 other cases, however, late gadolinium enhancement showed significant anomalies characterized in one patient by extensive areas of subepicardial fibrosis of the left ventricle, suitable with arrhythmogenic left dominant dysplasia; in another patient, a marked trabeculation of left ventricular medium apical segments suitable with non-compaction myocardium was present. CMR may identify cases of structural heart disease in subjects with OT PVCs and apparently normal electrocardiogram and echocardiogram examinations. A preliminary screening with CMR may be considered before any further invasive electrophysiology assessment and therapeutic planning.

Aims Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF). Methods and results Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) Conclusion RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

Background: Colorectal cancer is one of the most common tumors for both men and women: in the United States, it represents the third leading cause of new cancer cases and cancer-related deaths. The prognosis is directly related to tumor infiltration in the mesorectum and lymph node metastases. In particular, it’s important to define the distance between lymphadenopathy and mesorectal fascia, as this has repercussions on surgical planning. This study aimed to evaluate the agreement among observers with different abdominal MRI expertise and intra-observer reliability in lymph nodes size and feature definition. Methods: In this retrospective study, MRI examinations were performed in 88 patients with rectal adenocarcinoma treated with primary surgery. Four observers, two senior physicians, and two junior physicians, analyzed MRI scans in two sessions 30 days apart and determined the size and morphological pattern of regional lymph nodes. Statistical analysis included the determination of Fleiss kappa (k) coefficient, Cohen's Kappa coefficient, and confidence intervals (CI). Results: The inter-observer reproducibility for MRI N-staging was good among the four physicians (kappa = 0.65; CI 0.45–0.77). Reproducibility between the two senior physicians had a kappa of 0.68 (CI 0.62–1.00), while between the two junior physicians had a kappa of 0.61 (CI 0.33–0.89). Inter-observer reproducibility was excellent for mesorectal, inferior mesenteric, and internal iliac lymph nodes (kappa values of 0.89, 0.82, and 0.80 respectively). For the other two nodal stations (superior and middle rectal lymph nodes, sacral lymph nodes), there was a good interobserver reproducibility (kappa between 0.70 and 0.77).The intra-observer reproducibility of interpretations of the MRI overall N staging progressively decreased among observer B (kappa= 0.85), observer C (kappa= 0.59), and the other two physicians. There was a significant difference in lymph nodes measurements between the first and second sessions in observer A (p ≥ 0.05). Excellent intraobserver reproducibility was found for mesorectal lymph nodes; the lowest intraobserver reproducibility values were found for presacral and lateral sacral lymph nodes.Conclusions: Although the low accuracy of MRI in assessing the involvement of metastatic lymph nodes in rectal cancer, this study demonstrates good interobserver reliability among physicians with different abdominal MRI experiences.

Cardiovascular diseases remain among the leading causes of death worldwide and sudden cardiac death (SCD) accounts for ~25% of these deaths. Despite its epidemiologic relevance, there are very few diagnostic strategies available useful to prevent SCD mainly focused on patients already affected by specific cardiovascular diseases. Unfortunately, most of these parameters exhibit poor positive predictive accuracy. Moreover, there is also a need to identify parameters to stratify the risk of SCD among otherwise healthy subjects. This review aims to provide an update on the most relevant non-invasive diagnostic features to identify patients at higher risk of developing malignant ventricular arrhythmias and SCD.

Background: Today, the goal of surgery is to achieve oncological efficacy with the lowest complication rate. Computed Tomography (CT)-guided cryoablation is proposed as a safe and effective technique. We report, our series of small renal masses treated with cryoablation in elderly (> 70 years). Methods: From May 2014 to April 2019, 32 patients with median (IQR) age of 75.5 years (range 71-80) with small renal masses (< T1a) diagnosis, clinical anesthesia contraindications to nephron-sparing surgery or patient’s will previous informed consent have been selected at our Urology Department. All patients underwent CT-guided cryoablation, preceded by needle biopsy. The cryoablation consisted in a procedure with an argon/helium gas-based system under local anesthesia. The follow-up included CT abdomen at 3, 6 and 12 months. The definition of incomplete treatment was the persistence of the lesion contrast enhancement (CE) at the end of the scan; the definition of relapse was the appearance of the CE to the 6-month control CT.Results: The median follow-up was 30 months (IQR 1-59). The median size of the tumor was 3.85 cm (IQR 1.6-4.5). All patients underwent lesion biopsy resulting in diagnosis of Renal Cell Carcinoma (RCC) in 29 patients (90.7%) and oncocytoma in 3 patients (9.3%). A median of 2 cryoprobes (IQR 1- 3) was used and 2/3 cycles of freeze-thaw of the duration of 10 minutes or 5 minutes were performed. Complications were: 3 asymptomatic transitional perirenal effusion, 2 lumbar pain well-controlled by analgesic drug. Hospital stay was 2 days (range 1-3). No case showed incomplete treatment and local relapse or metastates at the CT abdomen-pelvis with contrast medium at 12 months. Conclusions: This study shows the efficacy and safety of percutaneous cryoablation of small renal masses in elderly population. The procedure is easy to perform, with low complication rates and well tolerated by the elderly patients.

Cardiac tumors (CTs) are extremely rare, with an incidence of approximately 0.02% in autopsy series. Primary tumors of the heart are far less common than metastatic tumors. CTs usually present with any possible clinical combination of heart failure, arrhythmias, or embolism. Echocardiography remains the first diagnostic approach when suspecting a CT which, on the other side, frequently appears unexpectedly during an echocardiographic examination. Yet, cardiac tomography and especially magnetic resonance imaging may offer several adjunctive opportunities in the diagnosis of CTs. Early and exact diagnosis is crucial for the following therapy and outcome of CTs.

Chronic myeloid leukemia (CML) is a myeloproliferative disorder characterized by neoplastic transformation of pluripotent cells due to a typical cytogenetic and molecular mutation known as Philadelphia (Ph) chromosome. In 2001, the introduction of the tyrosine kinasis inhibitor (TKI) imatinib as a therapeutic strategy for CML with PH chromosome mutation represented an important step towards treatment of these patients, and nowadays, this drug represents the gold therapeutic standard in this clinical setting. A second generation of TKIs (dasatinib, nilotinib, and bosutinib) showed an effective action in all patients with mutations resistant to imatinib. Ponatinib is a third-generation TKI and is the only inhibitor with activity against T3151 mutation. The impact of ponatinib on cardiovascular events was first evaluated in the PACE trial. We therefore report and discuss most relevant evidence currently available on cardiovascular events associated with the use of ponatinib. Though many exams can be used for diagnosis and follow-up of this kind of cardiotoxicity, echocardiography seems to have a pivotal role thanks to its feasibility, availability, and low cost.

Mitral annular calcification (MAC) can resemble an intracardiac mass and it is defined as a chronic degeneration of the mitral annulus. Often reported is caseous mitral annulus calcification (CMAC), a periannular, extensive calcification resembling a tumor. We report the case of a 68-year-old woman who had been hospitalized for palpitations and dyspnea. The transthoracic and transesophageal echocardiography revealed a non-homogeneous, slightly mobile, round mass, attached to the ventricular side of posterior mitral leaflet, with central echo-lucent area and without acoustic shadowing. Therefore, a cardiac magnetic resonance (CMR) was performed; delayed enhancement sequences showed a non-enhanced central core surrounded by a hyperenhanced rim (fibrous cap). To confirm the diagnosis, a multidetector computed tomography (MDCT) was performed; the MDCT showed a hyperdense mass with a hypodense center and a calcified peripheral rim. The central content had heterogeneous fluid density without significant contrast enhancement. The MDCT findings were considered highly suggestive of CMAC. CMR may be useful for the identification and definition of pericardial and myocardial masses and CMAC.

Parachute mitral valve (PMV) is a congenital cardiac malformation where typically all tendons chordae converge and insert into one major papillary muscle. We report the case of 27-year-old man affected by Hodgkin’s lymphoma-mixed cellularity subtype with polychemotherapy treatment and Barrett’s esophagus who came to our attention for routine echocardiographic exam and evaluation of left ventricular function. In the presence of normal left ventricular systolic function and mild-moderate mitral regurgitation, a careful examination of mitral apparatus showed a single papillary muscle suspected for PMV. In the presence of Barrett’s esophagus, the patient was further assessed cardiac magnetic resonance (CMR) that confirmed the diagnosis of PMV and excluded other associated congenital anomalies. Despite the rare incidence of PMV and a diagnosis generally based on transesophageal echocardiography, CMR could represent a useful tool, in selected cases, to confirm the diagnosis of PMV, identify other possible congenital anomalies, and assess ventricular and valvular function.

Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Echocardiogram unexpectedly showed the presence of diastolic flow from the pulmonary trunk in parasternal short-axis view. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern. Coronary angiography hence showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary and the right coronary arteries. Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.

We report the case of an incomplete diagnosis of chronic thromboembolic pulmonary hypertension, with relevant prognostic implications, missing the presence of a primary pulmonary artery angiosarcoma. After the late neoplasm diagnosis, the patient, treated for months with riociguat, was considered inoperable and died soon after. This case highlights the need to manage patients with suspected pulmonary arterial hypertension by expert referral centers with specific and multi-professional expertise (heart and thoracic imaging) in order to avoid incomplete or delayed diagnoses.

We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent ‘migration’ of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly ‘wander’ within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly ‘wandering’ cases.

Background. Cardiac magnetic resonance imaging (cMRI) has recently emerged as a new noninvasive imaging modality that offers superior structural and functional assessment of the heart. cMRI benefits from a large field of view but, consequently, may capture incidental extracardiac findings (IEFs). We aimed to evaluate the frequency and significance of IEFs reported from clinically indicated cMRI scans. Methods. 742 consecutive patients (402 males and 340 females) referred to the Cardiac Magnetic Resonance Center of our University Hospital between January 2015 and December 2016 for clinically indicated cMRI were retrospectively enrolled for the evaluation of IEF prevalence and relevance. The median age of the subjects was 51 years (range: 5–85 years). Results. A significant number of patients who underwent cMRI had incidental and clinically significant IEFs (2% of the population, 11.4% of cases). cMRI allowed a correct diagnosis in 116/131 cases with a diagnostic accuracy value of 88.5%. Conclusions. IEFs on cMRI are not uncommon and lesions with mild or no clinical significance represent the most frequent findings. cMRI can characterize incidental findings with high accuracy in most cases.

Anomalous coronary arteries (ACAs) are rare but potentially life-threatening abnormalities of coronary circulation. Most of the variants are benign; however, some may lead to myocardial ischemia and/or sudden cardiac arrest. We report the case of a 75-year-old male complaining of exertion chest discomfort. Admission electrocardiogram on presentation showed sinus bradycardia with a slight elevation of ST-T in inferior leads. Troponin levels, however, were normal. Coronary angiography showed an anomalous right coronary artery (RCA) originating from the left main stem without significant stenosis. Cardio-CT confirmed the anomalous origin of the RCA from the left main stem and showed its anomalous course between the aorta and the pulmonary artery. The patient was deemed a candidate for surgery and transferred to a cardiac surgery center. Only the exact definition of the anatomic and clinical features of ACAs may allow the identification of the most appropriate and effective treatment. Multislice computed tomography may play a fundamental role in the diagnosis and treatment of ACAs.

Background The presence of viable stunned myocardium recovering after primary angioplasty is not easy to identify in the early phase of acute myocardial infarction (AMI) by non-invasive bed-side methods. We therefore aimed to assess whether a simple electrocardiogram parameter may be of help in identifying the presence of stunned viable myocardium recovering after reperfusion with primary angioplasty. Methods 14 consecutive patients with ST-elevation-AMI (STEMI) were enrolled in the study and underwent QT-duration assessment after admission: the difference between QT-corrected (QTc) in the ischemic areas and QTc values in non-ischemic areas was therefore calculated and compared with the presence and the extension of viable stunned myocardium, assessed by comparing akinetic/dyskinetic areas at admission echocardiography with akinetic/dyskinetic areas and extension of scar at 6-month cardiac magnetic resonance imaging (cMRI). Results In subjects with viable recovering myocardium 75% had a QTc max >440 msec (vs 17%, p.0.03); higher differential QTc values and smaller scar areas were found (33 msec vs -17 msec, 14% vs 27%, p 0.03, 0.06 respectively). Differential QTc values >0 were able to identify the presence of viable myocardium with an odds ratio of 35 (p

In patients with atrial fibrillation (AF), extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging has been associated with early recurrence of AF after catheter ablation. We present a case of a patient with extensive atrial fibrosis and AF recurrence. The study of late gadolinium enhancement with cardiac magnetic resonance imaging in patients with AF could be a valuable noninvasive tool for the selection of patients suitable for successful catheter ablation.

Cardiac fibromas are benign connective tissue tumors derived fromfibroblaststhat occur predominantlyin children andconstitutethesec-ond most common type (after the rhabdomyoma) of primary cardiactumoroccurringinthepediatricagegroup[1].Mostaredetectedinchil-dren younger than 10 years, and about one-third are diagnosed in in-fants younger than 1 year. Males and females appear to be equallyaffected. Cardiac fibromas are typically large tumors ranging from 3 to10cmin diameter.They usuallyoccurwithintheventricularmyocardi-um and much more frequently within the anterior free wall of the leftventricular wall or the inter-ventricular septum than in the posteriorleft ventricular wall or right ventricle [2]. Approximately 70% of fibro-mas are symptomatic, causing mechanical interference with intra-cardiac flow (usually with bulky intra-cavitary left ventricular or rightventricular tumors), ventricular systolic function (usually with largeintra-myocardial left ventricular tumors), or conduction disturbances(usually with tumors arising in the inter-ventricular septum). Themost common clinical manifestations are congestive heart failure(21%), ventricular tachy-arrhythmias (13%) and atypical chest pain(3.5%)[3].Suddencardiacdeathoccursin14%ofpatientswithfibromas,typically in infants. Cardiac fibromas do not show spontaneous regres-sion and surgical resection generally remains the treatment of choicefor these tumors in children.A 51-year old man (C.R.) was referred to the emergency room fortypical dizziness, sweating and vomit. Electrocardiogram showedsinus rhythm with Q wave in D1, D2, aVL and from V4 to V6 with Twave inversion from V4 to V6. Blood pressure at admission was150/100mmHg,troponin-Ivalueswerenormal.Thepatientwasthere-fore admitted to the acute cardiac care unit with a diagnosis ofsuspected acute coronary syndrome. Echocardiography showed, in offaxis views, a heterogeneous oval mass of the left ventricular lateralwall (5 × 3 cm) without involvement of mitral valve apparatus(Fig. 1a–b). Coronary angiography was normal.Cardiacmagneticresonanceimaging(cMRI),performedwitha1.5-Tmagnet(PhilipsAchieva)andacardiacphased-arraymulti-coil,showedin the mid-apical left ventricular lateral wall and inferior-lateral wallsegments a nodular intra-myocardial formation (5.3 × 3.6 cm) iso-intense in the sequences T1-TSE (turbo spin echo Fig. 2 left) and inCINE-TFE sequences (turbo field echo Fig. 2 right; Videos 1–3), hypo-intense in the sequences T2-SPIRR BB (black-blood — T2-short-tau-in-version recovery Fig. 3a–b; Video 4). In the sequences for the dynamicstudy of first pass a minimal and inhomogeneous enhancement aftergadolinium was evident (Fig. 4 left; Video 5). In late enhancementPSIR-TFE (phase sensitive inversion recovery turbo field echo) se-quences, the nodular formation was hyper-intense (Fig. 5; Video 6).A diagnosis of cardiac fibroma was therefore based on such cMRIfindings (iso-intense mass in cine“bright blood” balanced fast field-echo images and in T1, hypo-intense in T2-STIR, minimal enhance-ment with gadolinium at the dynamicfirst pass and hyper-intensein PSIR sequences). The patient did not undergo endo-myocardialbiopsy and surgical excision because of the large dimension of themass.Thecardiac fibromaisararebenigntumoroftheheart.Thefirsttoolto assess such lesion is echocardiography, which can provide informa-tion on the tumor's extent and on ventricular and valvular function.cMRImayimproveandhelpthediagnosisbythetissuecharacterizationof the lesion. cMRI allows the identification of cardiac and para-cardiacsuspicious masses; a precise definition of the extension and the rela-tionships as well as possible involvement of vascular and mediastinalstructures, the infiltration of the pericardium and relationships withnormal intra-cardiac structures may be obtained. Finally, the signalcharacteristics and contrast are useful for tissue characterization of

Papillary fibroelastoma is a rare benign cardiac tumor, second after cardiac myxoma as more frequent cardiac valvular tumor. The therapy is usually based on surgery according to size, mobility, symptoms, and risks of surgery. We report the case of a 67-year old female with transient ischemic attack. Echocardiography showed the presence of a round mobile formation localized on the atrial side of septal leaflets of tricuspid valve, first identified as an endocarditis vegetation. Cardiac magnetic resonance (cMRI) confirmed the presence of the mass and showed an isointense signal in T1-turbo spin echo sequences, hypointense in cine steady-state free precession and in first-pass sequences, and hyperintense in T2 and phase-sensitive inversion recovery with central hypointense core, with a suspected diagnosis of fibroelastoma. The patient underwent cardiac surgery and histology confirmed the presence of fibroelastic tissue with papillary extroflexions compatible with diagnosis of fibroelastoma. The use of cMRI may be useful in the evaluation of the exact position, dimensions, and nature of cardiac masses and fibroelastomas, diagnostic workup, and preliminary assessment before surgery.

We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancementmay be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m; indexed end-systolic volume, 25 mL/m). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m; indexed endsystolic volume, 19 mL/m). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3].