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Hemodynamic rounds and clinical pathology correlation: Evaluation of a polycythemic patient guided by imaging, hemodynamics, and endomyocardial biopsy.

ABSTRACT: A 32-year-old male with symptomatic polycythemia was investigated by hematologist for myeloproliferative malignancies and underwent five therapeutic phlebotomies. The identification of hypoxia on pulse oximetry later led to pulmonology evaluation that showed normal lung function tests as well as normal lung parenchyma and airways on advanced imaging. The absence of murmurs and significant precordial findings, normal chest X-ray, and unremarkable findings in electrocardiogram apart from first-degree heart block delayed the cardiac referral. Cardiac imaging showed a significant right to left shunt through a large oval fossa defect, mild hypoplasia of the right ventricle, normal right ventricular function and mild fibrosis within the myocardium. Hemodynamic assessment with test balloon occlusion led finally to a complete closure of the defect, which normalized the hypoxia. A step-by-step clinical approach finally leading to the management is presented in this clinicopathology correlation and hemodynamic rounds.

SUBMITTER: Sagar P

PROVIDER: S-EPMC9075555 | biostudies-literature | 2021 Oct-Dec

REPOSITORIES: biostudies-literature

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Hemodynamic rounds and clinical pathology correlation: Evaluation of a polycythemic patient guided by imaging, hemodynamics, and endomyocardial biopsy.

Sagar Pramod P Sivakumar Kothandam K

Annals of pediatric cardiology 20211001 4

A 32-year-old male with symptomatic polycythemia was investigated by hematologist for myeloproliferative malignancies and underwent five therapeutic phlebotomies. The identification of hypoxia on pulse oximetry later led to pulmonology evaluation that showed normal lung function tests as well as normal lung parenchyma and airways on advanced imaging. The absence of murmurs and significant precordial findings, normal chest X-ray, and unremarkable findings in electrocardiogram apart from first-deg ...[more]

PMID: 35527751

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Project description:BackgroundEndomyocardial biopsies (EMB) are an important diagnostic tool for myocarditis and other infiltrative cardiac diseases. Routinely, biopsies are obtained under fluoroscopic guidance with a substantial radiation burden. Despite procedural success, there is a large sampling error caused by missing the affected myocardium. Therefore, multiple (>6) biopsies are taken in the clinical setting. In cardiovascular magnetic resonance (CMR), late gadolinium enhancement (LGE) depicts areas of affected myocardium in myocarditis or in other infiltrative cardiomyopathies. Thus, targeted biopsy under real-time CMR image guidance might reduce the problem of sampling error.MethodsSeven minipigs of the Goettingen strain underwent radiofrequency ablation in the left ventricle. At least two focal lesions were induced on the lateral wall in five and the apex in two animals. Each ablation lesion was created by two consecutive 30 sec ablations (max. 30 W, temperature 60-64 °C). Biopsies were taken immediately after lesion induction using a commercially available 7 F conventional bioptome under fluoroscopic guidance at the ablation site. Afterwards the animals underwent CMR and lesion visualization by LGE at 3T. The lesions were then targeted and biopsied under CMR-guidance using a MR-conditional bioptome guided by a steerable catheter. Interactive real-time (RT) visualization of the intervention on an in-room monitor was based on radial FLASH with nonlinear inverse reconstruction (NLINV) at a temporal resolution of 42 ms. All samples underwent a standard histological evaluation.ResultsRadiofrequency ablation was successful in all animals. Fluoroscopy-guided biopsies were performed with a success rate of 6/6 minipigs - resulting in a nonlethal pericardial effusion in one animal. Visualization of radiofrequency lesions by CMR was successful in 7/7 minipig, i.e. at least one lesion was clearly visible. Localization and tracking of the catheters and the bioptome using interactive control of the imaging plane was achieved in 6/6 MP; however in the animal with a large pericardial effusion after EMB under fluoroscopy no further EMB was attempted for safety reasons. Biopsies under interactive RT-CMR guidance were successfully performed in 5/6 animals, in one animal the bioptome reached the lesion, however the forceps did not cut out a sample. Specimens obtained under CMR guidance contained part of the lesion in 6/15 (40%) myocardial specimens and in 4/5 (80%) animals in which samples were achieved. Conventional biopsies revealed ablation lesions in 4/17 (23.5%) specimens in 3/6 minipigs (50%).ConclusionFocal lesions induced by radiofrequency ablation in a minipig model are a useful tool for CMR-guided biopsy studies. In contrast to fluoroscopy, CMR provides excellent visualization of lesions. Interactive real-time CMR allows excellent passive tracking of the instruments and EMB provides significantly superior sampling accuracy compared to fluoroscopy-guided biopsies. Nonetheless, further improvements of MR-compatible bioptomes and guiding catheters are essential before applying this method in a clinical setting.

Project description:BackgroundDiagnostic accuracy of endomyocardial biopsy could improve if clinically safe magnetic resonance (MR)-compatible bioptomes were available. We explored two novel MR-compatible cardiac bioptomes for performance, safety, and clinical viability, employing in vivo minipig trials and phase-contrast synchrotron radiation computed microtomography (SRµCT).MethodsAnalysis of ex vivo obtained pig endomyocardial biopsies was performed using phase-contrast SRµCT and conventional two-dimensional histology. The technical performance was evaluated by measuring volume, inner and outer integrities, compression, and histological diagnostic value in 3 sets (6 per set) of biopsies for each experimental bioptome. The bioptomes were tested in vivo in 3 healthy minipigs per bioptome. The clinical feasibility was evaluated by procedural and cutting success as well as histological diagnostic value.ResultsThe bioptome with the 'grind-grind' design achieved similar values to control in compression (p = 0.822), inner (p = 0.628), and outer (p = 0.507), integrities ex vivo. It showed a better performance in the in vivo real-time MRI setting demonstrating a higher cutting success (91.7%) than the 'grind-anvil' (86.2%) design. In both ex vivo and in vivo evaluations, the 'grind-grind' design displayed sufficient diagnostic value (83% and 95%). The 'grind-anvil' design showed adequate diagnostic value both ex vivo and in vivo (78% and 87.5%) but was not comparable to control according to the three-dimensional (3D) analysis.ConclusionA novel MR-compatible bioptome was identified as plausible in a clinical setting. Additionally, SRµCT and subsequent 3D structural analysis could be valuable in the label-free investigation of myocardial tissue at a micrometer level.Relevance statementImplementation of MR-guided biopsy can improve animal studies on structural myocardial changes at any point in an experimental setup. With further improvements in guiding catheters, MR-guided biopsy, using the new bioptome, has a potential to increase quality and diagnostic accuracy in patients both with structural and inflammatory cardiomyopathies.Key points• Novel MR-compatible bioptomes show promise for a clinical application. • SRµCT enabled detailed analysis of endomyocardial biopsies. • The bioptomes showed adequate in vivo performance without major complications.

Dataset Information

Hemodynamic rounds and clinical pathology correlation: Evaluation of a polycythemic patient guided by imaging, hemodynamics, and endomyocardial biopsy.

Publications

Hemodynamic rounds and clinical pathology correlation: Evaluation of a polycythemic patient guided by imaging, hemodynamics, and endomyocardial biopsy.

Similar Datasets

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