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Background To assess low-contrast areas such as plaque and coronary artery stenosis, coronary computed tomography angiography (CCTA) needs to provide images with lower noise without increasing radiation doses. Purpose To develop a deep learning-based noise-reduction method for CCTA using four-dimensional noise reduction (4DNR) as the ground truth for supervised learning. Material and Methods \We retrospectively collected 100 retrospective ECG-gated CCTAs. We created 4DNR images using non-rigid registration and weighted averaging three timeline CCTA volumetric data with intervals of 50 ms in the mid-diastolic phase. Our method set the original reconstructed image as the input and the 4DNR as the target image and obtained the noise-reduced image via residual learning. We evaluated the objective image quality of the original and deep learning-based noise-reduction (DLNR) images based on the image noise of the aorta and the contrast-to-noise ratio (CNR) of the coronary arteries. Further, a board-certified radiologist evaluated the blurring of several heart structures using a 5-point Likert scale subjectively and assigned a coronary artery disease reporting and data system (CAD-RADS) category independently. Results DLNR CCTAs showed 64.5% lower image noise ( P 0.1). The intra-observer agreement of CAD-RADS in the DLNR image was excellent (0.87, 95% confidence interval = 0.77–0.99) with original CCTAs. Conclusion Our DLNR method supervised by 4DNR significantly reduced the image noise of CCTAs without affecting the assessment of coronary stenosis.

Chronic thromboembolic pulmonary hypertension (CTEPH), which is classified as group 4 pulmonary hypertension (PH) in the 2015 European Society of Cardiology/European Respiratory Society guidelines for the diagnosis and treatment of PH, is regarded as a complication of pulmonary embolism and is caused by the transformation of incompletely resolved thrombi into fibrous tissue that occludes the pulmonary arteries. The current established reference standard curative therapy for CTEPH is pulmonary endarterectomy (PEA), which provides good long-term outcomes with a low mortality rate. For patients with inoperable disease with inaccessible lesions and risk factors for surgery or patients who are diagnosed with residual or recurrent PH after PEA, medical therapy with riociguat is recommended. Balloon pulmonary angioplasty (BPA) is an emerging alternative treatment option for patients with inoperable disease or those with residual or recurrent PH after PEA. BPA has been reported to improve hemodynamics, cardiac function, exercise capacity, and symptoms, as well as PEA. A detailed assessment of thromboembolic lesions in pulmonary arteries by using multiple imaging techniques and treatment strategies with multiple staged procedures based on the patient's condition is important for safe and effective BPA. However, this new technique may still induce life-threatening complications, such as reperfusion pulmonary edema, wire perforation, vessel dissection, and vessel rupture. Meticulous attention to technique is mandatory to minimize serious complications owing to the nature of the anatomic territory involved. The authors summarize the current roles, goals, and complications of BPA in patients with CTEPH and demonstrate ways to formulate an effective and safe treatment strategy. The future perspective of BPA is also discussed.

Background To improve myocardial delayed enhancement (MDE) CT, a deep learning (DL)-based post hoc denoising method supervised with averaged MDE CT data was developed. Purpose To assess the image quality of denoised MDE CT images and evaluate their diagnostic performance by using late gadolinium enhancement (LGE) MRI as a reference. Materials and methods MDE CT data obtained by averaging three acquisitions with a single breath hold 5 minutes after the contrast material injection in patients from July 2020 to October 2021 were retrospectively reviewed. Preaveraged images obtained in 100 patients as inputs and averaged images as ground truths were used to supervise a residual dense network (RDN). The original single-shot image, standard averaged image, RDN-denoised original (DL

We present the case of an 82-year-old man whose left coronary ostium became obstructed 15 months after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve. The patient underwent TAVR for symptomatic severe aortic stenosis with no complications. Fifteen months after the initial TAVR, the patient complained of chest pain while exercising, and the exercise stress myocardial perfusion scintigraphy demonstrated the development of regional myocardial ischemia in the region of the left coronary artery. Coronary angiography implied severe stenosis in the ostium of the left coronary artery. Computed tomography angiography and intravascular ultrasonography indicated a soft tissue component along with stent struts, which was considered to cause delayed coronary obstruction. Our report emphasizes the importance of having a low threshold for clinically suspecting delayed coronary obstruction in patients who have undergone TAVR, even after several years of the procedure. Learning objective Delayed coronary obstruction (DCO) should be suspected in patients presenting with new ischemic symptoms after transcatheter aortic valve replacement (TAVR). DCO may occur even in the case of TAVR with a balloon-expandable prosthetic valve, on antithrombotic regimens, and several years after the initial procedure.

Identification of the Adamkiewicz’s artery (AKA) prior to the operation is one of the spinal cord ischaemia preventive measures. A 75-year-old man presented with the rapid expansion of thoracic aortic aneurysm. Collateral vessels from the right common femoral artery to the AKA were observed on preoperative computed tomography angiography. The stent graft was successfully deployed through the contralateral side via a pararectal laparotomy to avoid collateral vessel injury supplying the AKA. This case highlights the significance of preoperative identification of collateral vessels to the AKA.

PURPOSE: To evaluate the image quality of high-spatial-resolution two-dimensional (2D) late gadolinium enhancement (LGE) cardiac MRI compared with conventional normal-resolution LGE MRI. MATERIALS AND METHODS: This prospective study included participants suspected of having cardiomyopathy who underwent cardiac MRI between March 2021 and December 2021. Normal-resolution and high-resolution 2D LGE sequences (inversion recovery [IR] and phase-sensitive inversion recovery [PSIR]) were performed at 3 T. Resolution was compared between normal-resolution and high-resolution images obtained in a quality assurance phantom. In vivo image quality and resolution were evaluated qualitatively using a five-point scoring system. Receiver operating characteristic curve analysis was used for LGE detection performance. Border sharpness was assessed with profile curve measurement. The contrast-to-noise ratio (CNR) between hyperenhancement and remote myocardium and LGE detection performance were calculated using normal-resolution IR images as the reference. RESULTS: In total, 120 participants were evaluated (mean age, 56 years ± 17 [SD]; 72 men). Features smaller than 1 mm were detectable only on high-resolution images of the phantom. In vivo, the image resolution score with high-resolution LGE was 4.14–4.24, which was higher than the normal-resolution LGE reference score of 2.99 (P < .05). Border sharpness was higher in high-resolution images (P < .001). Receiver operating characteristic curve analysis revealed no evidence of a difference in LGE detection between normal-resolution and high-resolution images. There was also no evidence of a change in CNR of LGE in IR and PSIR magnitude compared with reference images. CONCLUSION: Comparison of image quality in 2D high-resolution and normal-resolution LGE cardiac MRI demonstrated the highest resolution for high-resolution IR and high-resolution PSIR magnitude sequences. Keywords: Cartilage Imaging, MRI, Cardiac, Heart, Imaging Sequences, Comparative Studies Supplemental material is available for this article. © RSNA, 2022

Comprehensive appreciation of the 3-dimensional anatomy of the living heart is essential for accurate diagnosis and establishment of safe interventional treatment by clinical electrophysiologists. Three-dimensional images displayed on a 2-dimensional surface usually undergo distortion and are not considered a real 3-dimensional representation because they cannot provide accurate depth perception. Currently, the availability of 3-dimensional visualization techniques, including 3-dimensional printing, 3-dimensional projectors, 3-dimensional monitors, and virtual reality, is limited owing to their limited user-friendliness and high costs. The authors discuss an alternative conventional approach of a cross-eyed method for viewing stereoscopically displayed images for better appreciation of real 3-dimensional images based on a simple technique.

Because endovascular abdominal aortic repair (EVAR) lowers the lumbar arterial blood flow, we hypothesized that the volume of the psoas muscle decreases after surgery. When internal iliac artery (IIA) embolization is performed, the lumbar arterial blood flow further decreases; therefore, we also hypothesized that the decrease in the volume of the psoas muscle becomes more significant. This study was performed to assess the volume change in the psoas muscle after EVAR.Fifty-three consecutive patients who underwent EVAR from January 2016 to December 2016 were included. The psoas muscle volume was measured by preoperative and postoperative computed tomography (CT). Postoperative CT scans were performed 6-12 months after EVAR. Axial CT images with a 2-mm slice thickness were used to measure the psoas muscle volume. Data were transferred to a 3-dimensional workstation, and the psoas muscle volume was measured.In the EVAR group, the volume of the psoas muscle decreased by an average of 5.8 mL (4.6%) from 114.8 ± 32.0 mL preoperatively to 109.0 ± 30.3 mL postoperatively (P 0.01). There was a significant difference in the change in the psoas muscle volume between patients with and without IIA embolization (embolization group: preoperative 118.1 ± 31.0 mL, postoperative 107.5 ± 29.2 mL, mean volume change rate -8.8%; nonembolization group: preoperative 114.0 ± 32.3 mL, postoperative 109.4 ± 30.7 mL, mean volume change rate -3.6%; P 0.05).The psoas muscle volume is reduced with EVAR. Moreover, when the IIA is embolized, the psoas muscle volume is further reduced.

During the COVID-19 pandemic in 2020, an 81-year-old afebrile woman was transported to our institute at 44 minutes after she was found to have global aphasia and weakness of the right extremities. The onset time was unclear. CT showed an occlusion of the left middle cerebral artery without early ischemic changes. MRI revealed a negative fluid-attenuated inversion recovery (FLAIR) pattern, in which several small acute infarcts were seen in diffusion-weighted images with no corresponding hyperintensity lesions on FLAIR. Accordingly, intravenous thrombolysis with alteplase (0.6 mg/kg, the dose approved in Japan) was administered at 1,660 minutes after the last known well and 116 minutes after the symptom recognition. An immediate internal carotid angiogram showed severe stenosis at the distal end of the horizontal portion of the left middle cerebral artery. In the follow-up angiogram at 164 minutes after the symptom recognition, the stenotic lesion almost resolved with the restoration of quick and nearly complete antegrade flow. Her symptoms also resolved promptly. Although the use of MRI is recommended to be minimized in the emergency stroke management during the COVID-19 pandemic, MRI is occasionally mandatory for patient selection, such as cases with unclear onset to perform intravenous thrombolysis. The individualized protected code stroke is essential and must be well considered by each institute for diagnosing patients by selecting appropriate modalities.

Fukuyama-type congenital muscular dystrophy (FCMD) is severe, childhood-onset muscular dystrophy. Recently, our group has discovered a potential treatment using antisense oligonucleotides. Therefore, an effective, reliable, and objective method of assessing muscle is needed. Ultrasound is a minimally invasive tool that can be applied without radiation exposure or pain. Evaluating tissue stiffness by shear wave elastography (SWE) has especially recently attracted attention. Here, we aimed to evaluate SWE value of the upper limb muscles: biceps brachii, triceps brachii, brachioradialis, abductor pollicis brevis, and abductor finger muscle in patients with FCMD. Upper extremity function was evaluated by visual muscle ultrasound analysis (VMUA) and SWE in 13 patients with FCMD and 20 healthy controls. The motor function evaluation tool was used to evaluate motor function, and the correlation with the dynamics of the SWE was determined. VMUA scaled using the Heckmatt scale was higher in patients with FCMD. SWE was also significantly higher and stiffer in the biceps brachii and brachioradialis in patients with FCMD. Furthermore, the severity of FCMD symptoms was correlated with muscle stiffness. We conclude that VMUA and SWE can be useful tools for monitoring muscle atrophy and upper limb function in patients with FCMD.

Surgical treatment is an effective therapy and the gold standard for patients with left ventricular outflow tract obstruction (LVOTO) and drug‐refractory symptoms. However, it is difficult to arrange a concrete surgical plan due to the heterogenous and complex cardiac anatomy. Three‐dimensional (3D) printing is an emerging technology that is able to reproduce complex cardiac anatomy. Here, we present two patients with LVOTO in whom we created 3D printed models. In these two patients, we compared the 3D printed model and the intraoperative findings and confirmed that the 3D printed model we created could reproduce the complex cardiac anatomy including the interventricular septum, papillary muscles, and abnormally thickened chordae. By using 3D printed models, cardiologists and surgeons can comprehend the complex 3D cardiac structure and spatial positional relationship preoperatively and perform surgical rehearsal. 3D printing could be a valuable tool for the management of patients with LVOTO.

The aim was to investigate the time savings and plane accuracy of multivendor head computed tomography (CT) using the intelligent work aid with automatic reformatting of the axial head image at the orbitomeatal line. Materials and methods We retrospectively reviewed 781 head CTs (median, 70 years; 441 men) collected by CT systems from 3 vendors. In addition to the orbitomeatal line image reformatted by a CT specialist as a reference, we obtained the fully automated orbitomeatal line image using the intelligent work aid. We calculated the offset angle from the reference of the automatically reformatted image. We defined the large offset angle groups as those with an offset angle greater than 3 degrees. Multivariate logistic regression was used to determine the independent factors for the large offset angle groups. We compared the postprocessing times measured using the intelligent work aid or by a CT specialist. Results With the intelligent work aid, 99.7% of CTs were automatically reformatted to the orbitomeatal line without error. Furthermore, 88.1% of CTs were within the 3 degrees' offset angle when compared with the reference produced by a CT specialist. The median offset angle from the reference was 1.41 degrees. Multivariate analysis showed that the offset angle of the positioning plane was an independent factor (odds ratio, 1.045; P = 0.005) for predicting the large offset angle group. Furthermore, this technique was 4 times faster (6.4 ± 0.7 seconds) than a CT specialist (25.6 ± 6.4 seconds). Conclusions The intelligent work aid can generate a fast and precise head CT image aligned at the orbitomeatal line, even in real-world clinical CTs. However, precise positioning remains essential.

Background Head and neck malignancies rarely cause reflex syncope. Three mechanistic patterns of reflex syncope are known in such patients: carotid sinus syndrome, glossopharyngeal neuralgia syndrome, and parapharyngeal space lesions syncope syndrome. There are few reports describing parapharyngeal space lesions syncope syndrome. Case summary A 61-year-old man with a history of head and neck cancer underwent left lingual resection and left anterior cervical lymph node dissection followed by chemoradiotherapy. Two months later, he experienced his first syncope and was admitted to our hospital for further investigation. During the first few days in the hospital, he experienced loss of consciousness. Carotid artery massage and cervical rotation-extension examinations revealed no abnormalities, and glossopharyngeal neuralgia was not observed. Cervical computed tomography showed recurrence of tongue cancer infiltrating the para-nasopharyngeal space. Consequently, the patient had sinus pause during the loss of consciousness; hence, we suspected parapharyngeal space lesions syncope syndrome. Pacemaker implantation was considered but could not be performed as the patient passed away because of the original malignancy. Discussion Parapharyngeal space tumours are often characterized by the absence of subjective symptoms, although symptoms such as neck swelling and discomfort in the throat have been reported. Parapharyngeal space lesions syncope syndrome is caused by tumour invasion into the parapharyngeal space, and there is no known trigger for syncope. Our case is unique because the patient’s first symptom of recurrence of tongue cancer infiltrating the para-nasopharyngeal space was repeated loss of consciousness.

Background Coronary computed tomography angiography (CCTA) non-invasively visualizes lipid-rich plaque. However, this ability is not fully validated in vivo. The current study aimed to elucidate the association of CCTA features with near-infrared spectroscopy-derived lipidic plaque measure in patients with coronary artery disease. Methods 95 coronary lesions (culprit/non-culprit = 51/44) in 35 CAD subjects were evaluated by CCTA and NIRS imaging. CT density, positive remodeling, spotty calcification, napkin-ring sign and NIRS-derived maximum 4-mm lipid-core burden index (maxLCBI4mm) were analyzed by two independent physicians. The association of CCTA-derived plaque features with maxLCBI4mm ≥ 400 was evaluated. Results The median CT density and maxLCBI4mm were 57.7 Hounsfield units (HU) and 304, respectively. CT density (r = -0.75, p Conclusions CT density

Very few studies have been performed to evaluate both the severity and site of aortic calcification (AC) in both end-stage kidney disease (ESKD) and diabetes mellitus (DM). The purpose of our study was to examine the utility of a newly developed three-dimensional (3D) visualization and quantification method compared with other methods to evaluate vascular calcification in ESKD patients with and without DM. Fifty patients with ESKD before initiating hemodialysis at our hospital were included in the present study. They were divided into the two groups, depending on the presence or absence of DM: Control group (n = 31) and DM group (n = 19). The volume and site of AC were evaluated via computed tomography (CT) scan using a 3D visualization and quantification method. Total calcification volume was significantly greater in the DM group than in the Control group. Calcification volume in the descending and abdominal aortas was greater in the DM group compared to the Control group. There were no significant differences in calcification volume in the aortic root, ascending aorta, and aortic arch. Calcification volume of the whole aorta, the descending aorta, and the abdominal aorta were each significantly correlated with age, diastolic blood pressure and pulse pressure. This study using a 3D visualization and quantification method demonstrated that AC was more severe and occurred more frequently in the abdominal aorta in ESKD patients with DM compared to those without DM. This method would enable us to precisely evaluate the volume and distribution of AC.

Traditionally, gross cardiac anatomy has been described mainly based on the findings in the dissection suite. Analyses of heart specimens have contributed immensely towards building a fundamental knowledge of cardiac anatomy. However, there are limitations in analyzing the autopsied heart removed from the thorax. Three-dimensional imaging allows visualization of the blood-filled heart in vivo in attitudinally appropriate fashion. This is of paramount importance for not only demonstration of cardiac anatomy for educational purposes, but also for the detailed anatomical evaluation in patients with acquired and congenital heart disease. In this review, we discuss the advantages of three-dimensional imaging, specifically focusing on virtual dissection, a volume rendering-based reconstruction technique using computed tomographic data. We highlight examples of three-dimensional imaging in both education and guiding patient management.

Inferences made regarding the postnatal anatomy of the atrial septum still tend to be based on developmental evidence. Although atrial septation is a well-defined process, it is remarkably complex and remains poorly understood. It is now established, however, that the process involves the conjugation of several myocardial structures and mesenchymal tissues of both intracardiac and extracardiac origin. The resultant postnatal morphology is equally complex, evidenced by the fact that, in the normal heart, only the floor of the oval fossa, along with its anteroinferior muscular buttress, are true anatomical septums. In this regard, septums can be defined as partitions that can be removed without creating communications with the extracavitary space. The true septal components are surrounded by grooves, which themselves largely represent infolding of the atrial walls. These anatomical features can now accurately be revealed using virtual dissection of CT data sets. These images, when carefully reconstructed, demonstrated the anatomy with as much accuracy as when hearts are dissected in the autopsy room. Such virtual dissection, furthermore, shows the components as they are seen within the chest, thus facilitating understanding for those intending to undertake interventional therapeutic procedures. By preparing such images, we show the complexity of the normal atrial septum and its surrounds. We show that it is only defects within the oval fossa, or the much rarer vestibular defects, which can appropriately be illustrated in the context of a normally constructed heart.

AIM To investigate whether iodine density measurements from contrast-enhanced dual-energy computed tomography (CT) data can non-invasively stage liver fibrosis. METHODS This single-center, prospective study was approved by our IRB with written informed consent. Forty-seven consecutive patients (26 men and 21 women; mean age, 63.1 years) with chronic liver disease underwent contrast-enhanced dual-energy CT of the liver (non-contrast, arterial, portal venous, and equilibrium phase images), followed by liver biopsy. Iodine density of liver and aorta were obtained by two independent observers. Iodine uptake of the liver (Δ Liver), representing the difference in iodine density between equilibrium phase and non-contrast images, was calculated and normalized by aorta (Δ Liver/Aorta). We accounted for contrast agent distribution volume by using hematocrit level. Accuracy of iodine density measurements for staging liver fibrosis was assessed by using receiver operating characteristic (ROC) curves. Multivariate linear regression analysis was used to assess the impact of independent variables (liver fibrosis stage and patient-related confounders) on iodine uptake. RESULTS The Δ Liver/Aorta significantly increased and moderately correlated with METAVIR liver fibrosis stage (ρ = 0.645, P

Knowledge of the anatomy of the membranous septum, as a surrogate to the location of the atrioventricular conduction axis, is a prerequisite for those undertaking transcatheter implantation of the aortic valve (TAVI). Equally important is its relationship of the virtual basal ring. This feature, however, has yet to be adequately described in the living heart. We analyzed computed tomographic angiographic datasets from 107 candidates (84.1 ± 5.2 years, 68% women) for TAVI. Using multiplanar reconstructions, we measured the height and width of the membranous septum, and the distances of its superior and inferior margins from the virtual basal ring plane. We also assessed the extent of wedging of the aortic root between the mitral valve and the ventricular septum. Mean heights and widths of the membranous septum were 6.6 ± 2.0, and 10.2 ± 3.1 mm, respectively, with its size significantly associated with that of the aortic root (P < 0.05). Its superior and inferior margins were 4.5 ± 2.3 and 2.1 ± 2.1 mm, respectively, from the plane of the basal ring. The inferior distance, the surrogate for the adjacency of the atrioventricular conduction axis, was ≤ 5mm in 91% of the patients. Deeper wedging of the aortic root was independently correlated with a shorter inferior distance (β = 0.0569, P = 0.0258). The membranous septum is appreciably closer to the virtual basal ring than previously appreciated. These findings impact on estimations of the risk of damage to the atrioventricular conduction axis during TAVI. Clin. Anat. 31:525-534, 2018. © 2018 Wiley Periodicals, Inc.

OBJECTIVE The aims of this study were to characterize focal myocardial damage of cardiac sarcoidosis by strain analysis and to compare it with late gadolinium enhancement (LGE) and fluorodeoxyglucose (FDG) positron emission tomography. METHODS We reviewed 208 segments from 13 cardiac sarcoidosis patients and measured the circumferential strain (Ecc) and the strain change per second (Ecc rate). The mean Ecc and Ecc rate values were compared between the FDG(+) and FDG(-), and the LGE(+) and LGE(-) segments using Welch's t test. RESULTS The peak and max Ecc rates were better in the LGE(-) segments than in the LGE(+) segments (-11.8 vs -8.9%, 40.5 vs 29.7%/s, both P < 0.001). The max Ecc rate was higher in the FDG(-) segments than in the FDG(+) segments (39.2 vs 31.7%/s, P < 0.001), but the peak Ecc did not differ between the FDG(+) and FDG(-) segments (-11.2 vs -10.1%, P = 0.17). CONCLUSIONS Strain analysis could reveal focal myocardial damage in the FDG(+) or the LGE(+) segments.

Even in modern clinical cardiology, basic auscultation skill is not obsolete and is still important because it can always provide a clue to an underlying pathophysiology. We demonstrate an unusual mechanism of pathological wide splitting of the second heart sound due to external compression of the pulmonary trunk in a patient with a giant coronary arterial aneurysm of the proximal left anterior descending artery. Echocardiography, when combined with a three-dimensional anatomical analysis with cardiac computed tomography, was useful for elucidating the mechanism of the abnormal heart sounds.

An asymptomatic 45-year-old man was referred to our hospital for detailed evaluation of a systolic ejection murmur. The intensity of the murmur increased on deep expiration and decreased on deep inspiration, showing so-called reversed Rivero-Carvallo's sign. Using cardiac magnetic resonance imaging, we demonstrated a characteristic respiratory-induced change in peak flow velocity in the right ventricular outflow tract, which was the basic mechanism of the reversed Rivero-Carvallo's sign in a case with straight back syndrome. Concomitant anatomical changes in the entire heart in relation to the thoracic cage were also clarified.

It is known that calcium-containing phosphate binders are more closely associated with the progression of vascular calcification than non-calcium-containing phosphate binders. In this study, we investigated the effect of the non-calcium-containing phosphate binder, lanthanum carbonate on the progression of coronary artery calcification and cardiovascular abnormalities compared to that of calcium-containing phosphate binder in chronic kidney disease patients during the early period after initiating hemodialysis. This was a randomized open-label study in which patients were divided into the calcium carbonate or lanthanum carbonate group. We evaluated blood samples, coronary artery calcification using high-resolution computed tomography, and cardiac abnormalities using echocardiography prior to and after initiating hemodialysis. Cardiac dimension and systolic function were significantly improved in the lanthanum carbonate group compared to those in the calcium carbonate group. Although statistically significant differences were not observed in all the patients, only among patients with moderate coronary artery calcification, the changes in coronary artery calcification score at 18 months were significantly smaller in the lanthanum carbonate group than those in the calcium carbonate group. The percent change in coronary artery calcification at 18 months was significantly correlated with the serum fibroblast growth factor 23 levels at 18 months (r = 0.245, P

Background The relationship between pulmonary vein (PV) arrhythmogenicity and its anatomy has been reported. However, that of the superior vena cava (SVC) has not been well discussed. Arrhythmogenic response induced by pacing stimulation at SVC might help with identifying SVC arrhythmogenicity. The purpose of this study was to investigate the relationship between the anatomical dilatation of SVC and the arrhythmogenic response induced by pacing at SVC. Methods Forty-three patients who underwent atrial fibrillation (AF) ablation were enrolled in this study. After PV isolation, scan pacing (up to triple extra stimulation following intrinsic sinus beats) was performed at SVC. The arrhythmogenic response was defined as following: (1) repetitive atrial responses, (2) non-sustained, and (3) sustained AF/ atrial tachycardia. To assess the dilatation of SVC, we measured the cross-sectional area of the SVC (SVC-area) using multi-planar reconstruction CT imaging. Results Arrhythmogenic responses were documented in 24 patients (Group 1). No arrhythmogenic responses were documented in the remaining 19 patients (Group 2). The SVC-area was significantly larger in Group 1 than Group 2 (3.1±0.9 vs. 2.2±0.8 cm 2 , P =0.004). A multivariate analysis revealed only SVC-area was associated with arrhythmogenic responses (odds ratio=2.87, CI 1.05–7.82, P =0.04). Furthermore, AF recurrence rate was significantly higher in patients with SVC-area>2.56 cm 2 than those with SVC-area 2 (9 [42.9%] of 21 vs. 3 [13.6%] of 22, P =0.026). Conclusion Dilatation of SVC was associated with an arrhythmogenic response, and the AF recurrence rate was significantly higher in patients with large SVC-area. Adjunctive catheter intervention for the SVC might be indicated in patients with a dilated SVC and an arrhythmogenic response.

To achieve the efficient usage of contrast material (CM) in high-pitch CT aortography, an appropriate duration of the CM injection is crucial. We used a modification of the double-level test bolus method for determination of proper injection duration with the aim of evaluating the image quality of tailored-duration CM injection compared with that of a fixed duration.The institutional review board approved retrospective review of 80 consecutive subjects who had undergone high-pitch 70-kVp CT aortography with a modified double-level test bolus method. The interval between peak enhancement at the aortic root and femoral artery was derived from the time/attenuation curves. A total of 40 subjects underwent CT aortography with individually set duration time from the results. The remaining subjects underwent CT aortography with a fixed-duration time. The density values at several parts of the aorta were assessed. The differences in image quality and CM amount used for each method were assessed by Welch test.The injection duration was almost 50% shorter (median, 15 seconds; range, 11-25 seconds) when individually tailored. The mean CM amount was reduced by 50% (46.2-23.9 mL, P0.01). The range of mean CT attenuation throughout the aorta was not significantly different between the 2 methods (316-327 HU and 305-321 HU, P0.05, respectively).The modified double-level test bolus method in high-pitch CT aortography can significantly reduce the amount of CM without adversely affecting image quality.

The location of the heart within the thorax varies significantly between individuals. The resultant diversity of the anatomical cardiac long axis, however, and its determinants, have yet to be systematically investigated. We enrolled 100 consecutive patients undergoing coronary arterial computed tomographic angiography, decomposing the vector of the anatomical cardiac long axis by projecting it to horizontal, frontal, and sagittal planes. The projected vectors on each plane were then converted into three rotation angles using coordinate transformation. We then measured the extent of aortic wedging, using the vertical distance between the inferior margins of the non-adjacent aortic sinus and the epicardium. We took the aortic root rotation angle to be zero when an "en face" view of the right coronary aortic sinus was obtained in the frontal view, defining leftward rotation to be positive. The mean horizontal, frontal, and sagittal rotation angles were 48.7° ± 9.5°, 52.3° ± 12.0°, and 34.0° ± 11.2°, respectively. The mean extent of aortic wedging, and the aortic root rotation angle, were 42.7 ± 9.8 mm, and 5.3° ± 16.4°. Horizontal rotation of the anatomical axis was associated with leftward and ventral rotation, and vice versa. Multivariate analysis showed aortic root rotation to be associated with horizontal cardiac rotation, while aortic wedging is associated with frontal and sagittal cardiac rotation. We have quantified the marked individual variation observed in the anatomical axis of the living heart, identifying the different mechanisms involved in producing the marked three-dimensional diversity of the living heart. Anat Rec, 300:1083-1092, 2017. © 2017 Wiley Periodicals, Inc.

Late-onset amyloidogenic transthyretin (ATTR) type familial amyloid polyneuropathy (FAP) shows features distinct from those of early-onset hereditary ATTR type FAP. We herein describe an asymptomatic 68-year-old man with late-onset ATTR type FAP whose serial annual electrocardiograms demonstrated progressive left bundle branch block. Latent but severe cardiac involvement seems to be one feature of late-onset ATTR type FAP, similar to senile systemic amyloidosis (SSA). Early differential diagnosis of late-onset ATTR type FAP from SSA is important because, currently, only the former has new therapeutic options available in Japan. The present case report, therefore, highlights the necessity of careful observation for periodic electrocardiograms.