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Controversies in monitoring disease

EuroEcho-Imaging 2014 session report

Transthoracic echo remains first-line imaging for monitoring of bicuspid aortic valve and screening for ischemia in patients undergoing radiotherapy, but CTA and MRA also have role to play.

With the development of multimodality cardiac imaging, the monitoring of cardiovascular conditions is evolving. In this session, two debates opposed experts on the choice of imaging techniques to monitor the aorta of patients with bicuspid aortic valve (BAV), and to screen for ischemic heart disease in those treated with radiotherapy for cancer.

The prevalence of BAV is approximately 1-2% in the general population, and ascending aorta dilatation occurs in 30-50% of cases, needing initial and long term monitoring. Drs Evangelista (Barcelona) and Cavalcante (Pittsburg) agreed that TTE is the first step for diagnosis and monitoring of patients, but that other techniques (CTA and even more especially magnetic resonance angiogram (MRA) to reduce radiation, especially in younger patients) are important, first at the initial work up if the aorta is enlarged, in order to validate the anatomy and dimensions of the aortic root and the whole aorta (aortic coarctation coexists in almost 50% of cases); and then if the aneurysmal aorta reaches the limits for considering intervention. The excellent spatial resolutions of CTA (0.6 mm) and MRA (0.8 mm) permit accurate estimation of the aneurysmal progression rate. Beyond the diameter, new techniques and software allow the estimation of aortic stiffness, wall stress and flow geometry using MRA, which may be useful in the future for refining indications for intervention.

The second debate addressed the growing interest of cardiologists for patients treated for cancer. Nowadays, 40% of patients with cancer survive beyond 10 years, so that the cardiovascular side effects of their treatments are increasingly apparent. Patients treated by chest radiotherapy are prone to coronary artery disease, especially if irradiated beyond 30-40 Gy, especially in young patients, or in those who already have other cardiovascular risk factors or diseases, and those who had concomitant chemotherapy (e.g. anthracyclines). Drs Picano (Pisa) and Chow (Toronto) agreed that the best strategy to monitor these patients request longitudinal and prospective studies. Rest and stress imaging can detect ventricular dysfunction and significant CAD with satisfying sensitivity and specificity, but perfusion imaging makes it possible to also visualize ischemia related to microcirculation rarefaction, which is also prognostic. Here again, while TTE is the first imaging modality, other imaging techniques and mostly cardiac MRA assess both perfusion and function, with higher resolution than SPECT, which in turn is more accessible.




Controversies in monitoring disease

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.