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      Asymptomatic apical aneurysm of the left ventricle with intracavitary thrombus: a diagnosis missed by echocardiography

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          Abstract

          Dear Editor, We report the case of a 63-year-old male, with a history of acute myocardial infarction (AMI) and angioplasty 10 years prior, who was asymptomatic at presentation. He stated that he had not undergone routine clinical follow-up and was therefore submitted to echocardiography for functional evaluation. Moderate dilation and dysfunction of the left ventricle (LV) were detected, although with limitation in the evaluation of the apex, without information on the presence of an aneurysm or thrombus. Coronary computed tomography angiography (CCTA) was performed in order to identify in-stent restenosis, and the images showed apparent subocclusion distal to the stent in the anterior descending artery (Figure 1A) and a large aneurysm with parietal thinning in the anterior/anteroseptal medial segments, septal/anterior apical segments, and apex of the LV. It was not possible to detect significant systolic ballooning, because there was a large thrombus lining the intracavitary portion and that was confused with normal wall thickness of the LV. The thrombus had an organized appearance, albeit without signs of calcification, and was markedly hypodense, with a fixed aspect and no contrast enhancement, which had likely made it difficult to identify in the initial (echocardiographic) assessment (Figures 1B and 1C). Figure 1 A: CCTA with a reconstruction curve showing probable subocclusion downstream of the stent (arrow). B,C: Cardiac computed tomography of the heart in the longitudinal axial plane, in a pseudo-two-chamber view, showing the region of the LV aneurysm with marked thinning of the medioapical anterior wall (2 mm thick - orange) and normal thickness in the anterior basal segment. Note the large thrombus simulating normal wall thickness of the LV (green). Ventricular aneurysm is a serious complication of transmural myocardial infarction (occurring in 5-38% of cases), being the most common mechanical complication, typically evolving to physical limitations and having a negative impact on quality of life(1-4). It is defined as myocardial ventricular wall thinning and dilation, with distinct margins, leading to akinesia or dyskinesia of one or more myocardial segments during ventricular contraction(1,2-5). It typically affects the anteroapical region of the LV, because the blood supply of the anterior wall is highly dependent on the anterior descending artery(2,3). Ventricular aneurysm develops within two to ten days after AMI, becoming apparent in the first year after the infarction, with an incidence of 30-35% in patients who have experienced AMI(4-6). As a secondary finding, intracavitary thrombus affects approximately 40-60% of patients(4) and results from the inflammatory process in the endocardial region affected by the AMI, being associated with the hypokinesia and hypercoagulability existing in the infarction, increasing the risk of a thromboembolic event after the third month in patients with ventricular aneurysm. There is a broad range of symptoms in LV aneurysms, ranging from none to dyspnea, heart failure, or angina, as well as severe manifestations such as acute pulmonary edema, thromboembolism, and ventricular rupture(5-7). In the treatment of severe refractory cases, surgical procedures, such as plication, excision/suture, imbrication, and patch interposition, are indicated(8). In the case presented here, despite the extensive area of left ventricular dyskinesia with aneurysm formation and adherent intracavitary thrombus, the patient remained asymptomatic, an uncommon presentation in large aneurysms, which was diagnosed only through CCTA, a noninvasive method that not only allows the diagnosis to be made but also provides accurate measurements and can be used in the postoperative follow-up(1,4-6,9-11). Routine screening tests, such as echocardiography, often fail to assess the apex of the LV, even with a good access window(1,2,7). In addition to allowing the diagnosis to be made, the CCTA findings promoted patient adherence to the treatment.

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          Coronary artery calcium score: current status

          The coronary artery calcium score plays an Important role In cardiovascular risk stratification, showing a significant association with the medium- or long-term occurrence of major cardiovascular events. Here, we discuss the following: protocols for the acquisition and quantification of the coronary artery calcium score by multidetector computed tomography; the role of the coronary artery calcium score in coronary risk stratification and its comparison with other clinical scores; its indications, interpretation, and prognosis in asymptomatic patients; and its use in patients who are symptomatic or have diabetes.
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            Cardiac magnetic resonance imaging and computed tomography in ischemic cardiomyopathy: an update*

            Ischemic cardiomyopathy is one of the major health problems worldwide, representing a significant part of mortality in the general population nowadays. Cardiac magnetic resonance imaging (CMRI) and cardiac computed tomography (CCT) are noninvasive imaging methods that serve as useful tools in the diagnosis of coronary artery disease and may also help in screening individuals with risk factors for developing this illness. Technological developments of CMRI and CCT have contributed to the rise of several clinical indications of these imaging methods complementarily to other investigation methods, particularly in cases where they are inconclusive. In terms of accuracy, CMRI and CCT are similar to the other imaging methods, with few absolute contraindications and minimal risks of adverse side-effects. This fact strengthens these methods as powerful and safe tools in the management of patients. The present study is aimed at describing the role played by CMRI and CCT in the diagnosis of ischemic cardiomyopathies.
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              Cardiac MRI and CT: the eyes to visualize coronary arterial disease and their effect on the prognosis explained by the Schrödinger's cat paradox

              In the present issue of Radiologia Brasileira, Assunção et al.(1) provide a detailed, accurate and updated description of cardiac MRI and CT techniques and their applications in cardiological diseases, more specifically in coronary artery disease, whose clinical relevance does not need to be highlighted. Two recent articles published in this journal have approached relevant aspects of the imaging study of the heart(2,3) as well. On the grounds of an extensive literature review, the authors describe how the current scientific developments and an appropriately conducted research have led to the present level of utilization, thus benefiting patients in the daily clinical routine, and how under some circumstances such imaging methods are still underutilized. The following points will be discussed: the scientific development and respective mechanisms, and the utilization of so accurate diagnostic methods. We must congratulate the authors on their initiative and on the production of that extremely educative text. Also, we should highlight the role played by the authors' institution of origin -Universidade Federal Fluminense - for continually supporting meritocracy and the most recognized researchers at both national and international levels. Even at difficult times like these Brazil is currently experiencing, one can find a silver lining ahead with institutions and individuals appreciating talented people involved in medical research that is not given the due consideration in our country. Such individuals are the ones who will emerge from the dark as true leaders of a future, active and engaged scientific community that will be the driving force for the development of our country. Similar efforts constitute common examples in the international scientific community. Fortunately, in some rare opportunities, Brazil almost always has a significant participation in such scientific cooperation. The CORE64(4) e C0RE320(5) studies represent personal examples as landmarks or seminal studies, validating coronary CT angiography and myocardial CT perfusion techniques, respectively. Such studies developed under the leadership of Dr. João Lima, from Johns Hopkins University, counted on the personal participation of this author and of the Heart Institute (InCor), Univerisity of São Paulo Medical School, whose patients represented approximately one third of both studies total included patients. The mentioned multicenter studies involved up to 16 countries and were published in recognized and prestigious international scientific journals - The New England Journal of Medicine and European Heart Journal, respectively. In addition to the obvious and significant scientific gains which have internationally projected the name of the institution in this area, the research process has allowed for the aquisition of advanced cardiac CT scanners which currently are the institution's structure for carrying on its clinical activities. As Americans say, a true "win-win situation", reflecting, in the research, the model that still nowadays allows for the InCor operation as an island of excellence (assistance to private and health plan patients in order to allow for providing a better assistance to SUS patients and those who do not count on health plan coverage). In our opinion, such a model of international cooperation should be encouraged and appreciated, together with the participation of skilled researchers selected on the basis of meritocracy. Brazilian institutions seem to be starting this type of collaboration that is highly effective and productive for the clinical and preclinical research. As regards the benefits and use of diagnostic methods in cardiology and general medicine, we are currently following the principles of "Choosing Wisely", "Less is More", and a series of other actions aimed at reasonably trying to restrain the exaggerated use of therapeutic, diagnostic and, particularly, imaging techniques in clinical situations where the benefits to the patient are not proved. We completely agree with such actions and even participate in some of them, principally because the resources on healthcare are restricted and, in fact, very limited for the huge needs of the general population in terms of health assistance. However, it is important to observe that, in the clinical diagnostic practice, the opposite situation is not infrequent, and patients only are submitted to diagnostic tests at advanced stages of disease, already with sequelae and severe complications which if otherwise had been early diagnosed, could be treated, potentially avoiding adverse, many times irreversible outcomes from advanced disease. A key issue is the lack of discussion about the medical responsibility under the ethical and legal point of view in cases of missed diagnoses and respective consequences which, in cardiology, may be even the patient's death. Particularly, for the emergency physician or for the cardiologist, in many situations of chest pain, critical diagnoses that could only be achieved with imaging methods are imprescindible. According to some physicians and lawyers involved in such a discussion, a reduction in tests, even those considered to be less necessary, shall be followed by an increase in the risk of missing the diagnosis. As an example, the American College of Radiology recommends that imaging studies are not performed in patients without suspicion of moderate to high pretest probability of pulmonary thromboembolism. Two percent of low-risk patients have pulmonary embolism whose diagnosis will be missed. Severe legal suits may result from such missed diagnoses. Lawyers would tell physicians that, in case anything goes wrong with their patients, nobody will thank them for saving resources of health by not requesting that diagnostic test. I believe that, in the indication of diagnostic studies, the dialogue with the patient to decide if a determined test is really necessary is the most relevant point in this discussion, together with a careful approach to be adopted on the basis of such diagnostic test results. Many of the situations involving excessive treatment result from an incomplete or erroneous understanding of the diagnostic tests results, particularly from those tests technologically more complex and recently introduced into the clinical practice, such as cardiac MRI and CT. Finally, my personal opinion is that, in coronary artery disease, the knowledge and observation, by both the physician an the patient, allowed by cardiac MRI and CT, and extremely well demonstrated by Assunção et al.(1), has an independent effect (that is difficult to explain) on the disease course and outcome. The quantum theory deals with the matter (light) duality behaving as both particle and wave. In the atom particles microcosms, the simple fact that observing a phenomenon changes the phenomenon itself has caused a great debate about the famous theoretical experiment of the Schrödinger's cat(6), where a cat is placed in a box with a vial of poison that would be released by the emission of a single quantum/photon of radioactive material, whose probability is impossible to predict with certainty, thus generating a paradox where before the box is opened, the cat is simultaneously alive and dead. The idea that the chance of the cat being either alive or dead is 50%/50% is inaccurate, uncertain and, in fact, the Schrödinger equation(6) with quotes from Paul Dirac can calculate how much alive and how much dead the cat is. However, as we observe the phenomenon by opening the box, the two waves (alive and dead) collapse into a single wave resulting in an either alive or dead cat. Already apologizing for the quantum/philosophical digression - in medicine, the observation of the phenomenon itself carries a relevant therapeutic value. Maybe this is just the effect from the partnership (duality) between the physician and the patient, that requires a fact, an image - something palpable, to develop around it, and that does not occur around a probability of disease (that, in general, is vague) and that, in the minds of both the physician and the patient involved in such a relationship, is not something actual and palpable. An optimum physician-patient partnership is, indeed, undoubtedly a major factor of success not only in the disease diagnosis and treatment, but also in the management and promotion of health.
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                Author and article information

                Journal
                Radiol Bras
                Radiol Bras
                rb
                Radiologia Brasileira
                Colégio Brasileiro de Radiologia e Diagnóstico por Imagem
                0100-3984
                1678-7099
                Jul-Aug 2018
                Jul-Aug 2018
                : 51
                : 4
                : 275-276
                Affiliations
                [1 ] Unidade de Radiologia Clínica (URC), São José dos Campos, SP, Brazil
                [2 ] Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
                Author notes
                Mailing address: Dra. Kamila Seidel Albuquerque. Unidade de Radiologia Clínica. Rua Teopompo de Vasconcelos, 245, Vila Adyana. São José dos Campos, SP, Brazil, 12243-830. E-mail: kamilaseidel@ 123456hotmail.com
                Article
                10.1590/0100-3984.2016.0199
                6124591
                262ae610-fca2-4cef-a85e-7afdecaa47b8

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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