Complex fractionated atrial electrograms (CFAEs) were consistently positioned on the interatrial septum, especially in the remodelled left atrium (LA). Semin Ultrasound CT MR If a patient had more than one stable AT, an attempt was made to map and ablate all ATs. Peribronchial thickening, also known as peribronchial cuffing, is a term used to describe a hazy radiologic appearance that results from excess fluid or mucus build-up, according to Radiopaedia.org. The high right atrium (RA), low RA, and coronary sinus were mapped with a decapolar catheter (Bard Electrophysiology, Inc., Lowell, MA, USA) and steerable duo-decapolar catheter (St. Jude Medical, Inc., Minnetonka, MN, USA) inserted through the left femoral vein. Knowing the common and also uncommon HRCT-presentations of these frequently encountered diffuse lung diseases is extremely important. Patients respond promptly to treatment with steroids. These data mean that no disorder can yield lung rockets, if not interstitial syndrome. interstitial pattern: one of several chest radiographic patterns associated with interstitial infiltration or thickening, including honeycomb pattern, miliary pattern, reticulonodular pattern, or septal lines. Does location of epicardial adipose tissue correspond to endocardial high dominant frequency or complex fractionated atrial electrogram sites during atrial fibrillation? Nonspecific interstitial pneumonia (NSIP) is by some considered as a specific entity, with specific histologic characteristics, but by others as a 'wastebasket' diagnosis, representing cases of idiopathic interstitial pneumonia that cannot be classified as UIP, DIP, or OP. Emphysema however is defined as airspaces without definable walls. Computed tomography (CT) imaging of case 1 pre‐ and post‐immunosuppression. Some less common interstitial lung diseases will also be presented because their HRCT presentation may be very typical, allowing for a 'spot diagnosis' in selected cases. Cardiogenic pulmonary edema: bilateral abnormalities, filling of alveoli, enlarged heart, rapid response to diuretics, ground-glass opacity due to filling of alveoli with fluid, gravitational distribution of the alveolar fluid. As seen on HRCT images, extensive peribronchovascular nodularity is strongly suggestive of sarcoidosis (Fig. When there is fibrosis, that does not fit into any of the common diseases with fibrosis always consider drug-related lung disease in the differential. All three patients were suffering from connective tissue disease, all cases were biopsy proven. Patients were evaluated by 24 or 48 h Holter monitoring or a 7-day event recorder at 3, 6, 9, and 12 months after the ablation and then at every 6 months thereafter. Patients resumed the anti-arrhythmic medications they had been taking before the catheter ablation. Solvent-dependent termination, size and stability in polyynes synthesized. Radiofrequency ablation was delivered at a target temperature of 48°C and power in the range of 25–35 W (Stockert generator, Biosense Webster, Inc., Diamond Bar, CA, USA or IBI 1500T11, St. Jude Medical, Inc., MN, USA) using a 4 mm open irrigated-tip catheter (Thermocool, Biosense Webster, Inc., Diamond Bar, CA, USA or Cool Path Duo, St. Jude Medical, Inc., MN, USA). The volume of the LA, excluding the LA appendage and PVs, was automatically measured in the reconstructed 3D cardiac CT image. Cystic bronchiectasis: 'signet ring sign'. Scherr D Dalal D Cheema A Cheng A Henrikson CA Spragg Det al. Miscellaneous processes that manifest septal thickening or simulate this feature. HRCT findings are usually nonspecific. The same endpoints of CFAE-guided ablation, in terms of significant reduction in the CFAE amplitude (>80%) or electrical silence, were applied during septal ablation. Symptoms include acute breathlessness, cough, wheezing, orthopnea, and paroxysmal nocturnal dyspnea. (A) Interatrial septal thickness measured 3.26 mm, so the patient was categorized into the first tertile. A stepwise ablation approach included circumferential pulmonary vein isolation followed by LA and right atrial CFAE-guided ablation. The mean IAST of each group was 4.69 ± 0.79, 6.44 ± 0.45, and 9.12 ± 1.42 mm (P < 0.001), respectively. This could be the result of an idiopathic form of fibrosis like idiopathic pulmonary fibrosis and non-specific interstitial pneumonitis or fibrosis in chronic hypersensitivity pneumonitis and longstanding sarcoid. Notice the lack of honeycombing in all three cases, excluding UIP as diagnosis. Notice progression on second scan 7 years later. The proportion of patients who showed CFAEs in the LA septal area was significantly higher as IAST getting thicker [45.8% (11/24) vs. 56.5% (13/23), 75.0% (18/24), P = 0.041]. Amiodarone was discontinued at least 1 month before the ablation procedure. Interlobular septal thickening (n=10) and architectural distortion (n=8) were less common findings. Opacifications range from ground glass to consolidation. HP is an allergic lung disease caused by the inhalation of a variety of antigens (farmer's lung, bird fancier's lung, 'hot tub' lung, humidifier lung). Notice how ill-defined these centrilobular nodules are. CFAE, complex fractionated atrial electrogram; IAST, interatrial septal thickness; LA, left atrial. All patients initially underwent circumferential antral ablation with the endpoint being the electrical PV exit and entrance block or dissociation. This HRCT-image also demonstrates subtle centrilobular opacity in a patient with subacute HP. We evaluated the association between interatrial septal thickness (IAST) with the extent of complex fractionated atrial electrograms (CFAEs) in the left atrium (LA) and acute procedural results in patients with persistent atrial fibrillation (AF). Respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, and desquamative interstitial pneumonia: different entities or part of the spectrum of the same disease process? Even though the detailed spatial distribution was not fully evaluated, septal positioning of CFAE was well correlated with the degree of IAST. The interatrial septal thickness (IAST) reflects the changes of the atrial wall in patients with atrial fibrillation (AF). The posterior LA fat thickness at the oesophagus was associated with increased AF burden independently of body mass index. Only third IAST tertile group was a borderline significant independent predictor of acute procedural failure (hazard ratio 4.701, 95% confidence interval: 0.903–24.468, P = 0.060). Organizing pneumonia is mostly idiopathic and then called cryptogenic, but is also seen in patients with pulmonary infection, drug reactions, collagen vascular disease, Wegener's granulomatosis and after toxic-fume inhalation. Differentiation has to be made on the basis of clinical and laboratory findings. Asked him if should be concerned about lung cancer (grandmother died from it even though never smoked), and he said to wait till ct results. The differentiation between NSIP and UIP has tremendous prognostic implication for the patient. Always look for small nodules along the fissures, because this is a very specific and typical sign of sarcoidosis. UIP: may show very similar HRCT findings. Search for other works by this author on: Relationship of epicardial adipose tissue with atrial dimensions and diastolic function in morbidly obese subjects, Potential atrial arrhythmogenicity of adipocytes: implications for the genesis of atrial fibrillation, Total and interatrial epicardial adipose tissues are independently associated with left atrial remodeling in patients with atrial fibrillation, Lipomatous hypertrophy of the interatrial septum, Atrial arrhythmias and lipomatous hypertrophy of the cardiac interatrial septum, Morpho-functional assessment of interatrial septum: a transesophageal echocardiographic study, Characteristics of complex fractionated atrial electrogram in the electroanatomically remodeled left atrium of patients with atrial fibrillation, Electrophysiologic characteristics of complex fractionated atrial electrograms in patients with atrial fibrillation, 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design, Clinical significance of induced atrial tachycardia after termination of longstanding persistent atrial fibrillation using a stepwise approach, A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate, Automated detection and characterization of complex fractionated atrial electrograms in human left atrium during atrial fibrillation, Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart, Human epicardial adipose tissue is a source of inflammatory mediators, Influence of epicardial adipose tissue and adipocytokine levels on cardiac abnormalities in visceral obesity, Effect of weight loss on cardiac synchronization and proinflammatory cytokines in premenopausal obese women, Proinflammatory phenotype of perivascular adipocytes: influence of high-fat feeding, Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation, Left atrial epicardial adiposity and atrial fibrillation, Clinical, electrocardiographic and morphologic features of massive fatty deposits (“lipomatous hypertrophy”) in the atrial septum, Lipomatous hypertrophy of the interatrial septum: a prospective study of incidence, imaging findings, and clinical symptoms, The importance of increased interatrial septal thickness in patients with atrial fibrillation: a transesophageal echocardiographic study, Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation, Long-term efficacy of catheter ablation for atrial fibrillation: impact of additional targeting of fractionated electrograms, Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies. Intralobular interstitial thickening results in an irregular reticular pattern smaller in scale than the reticular pattern of interlobular septal thickening. There are multiple small bilateral peripheral consolidations. On the left a patient with TB. If this patient was a bird-fancier we would first think hypersensitivity pneumonitis, but mostly these patients do not smoke. Focal or unilateral abnormalities in 50% of patients. Bilateral peripheral consolidations, sharply demarcated. Since this patient is a smoker we first think RB-ILD. On the left two different patients with similarl HRCT findings. A variety of underlying conditions, from infections to major trauma, can cause ARDS.Primary pulmonary risk factors include aspiration, pneumonia, toxic inhalation and pulmonary contusion. However, in most patients, interstitial thickening is not extensive. Edematous thickening. An important finding in extra-pulmonary ARDS is the symmetry of the abnormalities. Histology revealed alveolar sarcoid. Nowadays PCP is seen more in immunosuppressed patients, i.e. The presence of a few thickened interlobular septa can be seen in a wide variety of … Stages Now continue with the HRCT. The radiographic and pathologic abnormalities in patients can be classified into acute, subacute, and chronic stages. Usually located in the apical segments of upper lobes with cavitation Endobronchial spread: May occur in both primary and secondary TB, when the infection is not contained.Hematogenous spread (miliary TB): May occur in both primary and secondary TB, when the infection is not contained. There are multiple areas of consolidation. If generalized or diffuse, this will likely appear as a linear or reticular pattern, whereas if localized, it may appear as multiple tiny nodules. Acute procedural success rate was greater in the group of thinner IAST. Chronic Hypersensitivity Pneumonitis: mid zone fibrosis with mosaic pattern. When it extends beyond the centrilobular area to the edge of the secondary lobule, it may look as if it is cystic with walls. The HRCT of this patient with scleroderma and NSIP shows a fine subpleural reticular pattern in the upper lobes and more extensive abnormalities in the lower lung zones. In many cases however the patients are asymptomatic. On the left radiological pathological correlation of Langerhans cell histiocytosis in respectively nodular stage and early and late cystic stage. Answered on Nov 9, 2019. CFAE, complex fractionated atrial electrogram; CT, computed tomography; IAST, interatrial septal thickness. There is a good response to corticosteroid therapy and a good prognosis. In our experience, this is the thickest area of the interatrial septum, and allows for clear visualization of measurements on cardiac CT images. These cysts start as round structures but finally coalesce to become the typical bizarre shaped cysts of LCH. what does that mean ?" Drug-induced lung disease is a major source of iatrogenic lung injury. Interlobular septal thickening, thickening of fissures and thickening of the peribronchovascular interstitium (bronchial cuffing). On the left a patient with Sjogren's syndrome with LIP. Interatrial septal thickness was measured 1 cm inferior to the fossa ovalis on cardiac computed tomography (CT). On the left typical features of cardiogenic pulmonary edema The aims of this study were (i) to investigate the association between IAST and the extent of CFAEs in the LA and (ii) to assess the relationship of IAST with acute procedural results and clinical outcomes after catheter ablation. Representative examples of CFAE measurement in LA are shown in Figure 1. NSIP is by far the most common interstitial lung disease in patients with connective tissue disease. There are no cysts visible. Initial infection with consolidation, adenopathy and pleural effusion.Secondary TB : More than 100 entities manifest as diffuse lung disease. Lymphangitic Carcinomatosis results from hematogenous spread to the lung, with subsequent invasion of interstitium and lymphatics. In this case there is distribution in both lungs. An HRCT scan of the chest revealed nodular interlobular septal thickening (ILST) at the right lung base . It is important to note that we do not see the classic distribution of UIP, from which NSIP has to be differentiated. Idiopathic indicates unknown cause and interstitial pneumonia refers to involvement of the lung parenchyma by varying combinations of fibrosis and inflammation. Contrast-enhanced cardiac CT was performed using a dual-source, 64-multislice scanner (Somatom, Siemens, Inc., Germany). The correlation between IAST and body mass index was also not significant (r = 0.195, P = 0.103). There is smooth septal thickening and ground glass opacity in a more patchy distribution. The incidence of CFAEs in LA septal area was higher in thick IAST patients. Radiographics. Silicosis and Coal worker pneumoconiosis (CWP) are pathologically distinct entities with differing histology, resulting from the inhalation of different inorganic dusts. This can happen from inflammation, scarring, or a buildup of fluid. Fortunately only about 10 of these account for about 90% of all diffuse lung diseases, that are assessed by open lung biopsy. Consolidations have a protecting effect on the lung parenchyma under PEEP ventilation, while the ventrally located areas of more normal lung are most prone to the effects of barotrauma. On the left a patient with a NSIP. For permissions please email: firstname.lastname@example.org. This patient presented with acute dyspnoe and a normal chest film (not shown). It is characterized by uniform small nodules with a random distribution. Reticular abnormalities and signs of fibrosis are typically absent. Interlobular septal thickening and intralobular interstitial thickening was noted in 28 patients (65%), respectively. After double transseptal puncture, anticoagulation was started with unfractionated heparin, maintaining an activated clotting time between 300 and 350 s. We used 3D-mapping-guided geometry (NavX System, St. Jude Medical, Inc., St. Paul, MN, USA) for electroanatomical mapping in all patients. Chronic eosinophilic pneumonia is an idiopathic condition characterized by filling of the alveoli with eosinophils. Interatrial septal thickness measured 8.11 mm in this patient and the patient was categorized into the third tertile. (A) Pre‐immunosuppression with typical features of GLILD including nodular infiltrate, consolidation, and septal thickening. Lesions may show pleural tags or spiculae and give the impression of volume loss and slight retraction of the surrounding parenchyma (DD bronchogenic carcinoma). There are also areas of ground-glass and traction bronchiectases, but honeycombing is typically lacking. These abnormalities developed in several days and this rapid progression of disease combined with these imaging findings are very suggestive of the diagnosis AIP. Figure 1. Most lung diseases cause an increase in the radiodensity of the lung, and if this is due to a relative thickening of the interstitium- this will be manifest as increased prominance of the interstitial markings on the CXR. HRCT findings in Lymphangitic Carcinomatosis. Left atrium CFAE area index was defined as CFAE area/LA surface area × 100. HRCT findings in cardiogenic pulmonary edema. Alveolar edema manifests as … The mean anteroposterior LA diameter measured by transthoracic echocardiography was 43.8 ± 5.7 mm and the mean LA volume as measured by cardiac CT was 132.4 ± 42.0 mL. European Radiology 2001;11: 373-392. All patients had previously failed to respond to anti-arrhythmic drugs and had symptomatic AF. The major diagnostic problem is, that it may present with a large variety of radiologic patterns. The images on the left suggest the diagnosis hypersensitivity pneumonitis. (B) Interatrial septal thickness measured 9.68 mm, so the patient was categorized into the third tertile. These electrograms were recorded with the ablation catheter in a stable position for at least 6 s (to avoid artefacts) using the 3D automated software of the NavX system.12 This area was coded in white and pink on the CFAE map. AT, atrial tachycardia; CFAE, complex fractionated atrial electrogram; SR, sinus rhythm. Representative examples of IAST measurement are shown in Figure 1. The key findings in chronic hypersensitivity pneumonitis are: On the left a patient with chronic hypersensitivity pneumonitis. Multivariable analysis incorporating LA size and volume, CFAE area, CFAE area index, the presence of CFAEs in LA septal area, and IAST group was performed to evaluate the predictors of acute procedural failure during catheter ablation. The dominant feature is ground glass opacification and there are some thickened interlobular septa (arrow). It may present as organizing pneumonia, eosinophilic pneumonia, fibrosis, hypersensitivity pneumonitis or even as ARDS. Patients in the lowest IAST tertile showed significantly higher rates of acute procedural success by means of AF termination, either converting to sinus rhythm or AT during catheter ablation (87.5% vs. 73.9% vs. 62.5%, P = 0.048). Pneumocystis carinii pneumonia (PCP) or pneumocystis jiroveci as it is currently named, is an opportumistic infection in immunocompromised patients. Conglomerate masses in a perihilar location. Note the difference in severity of ground glass opacities and the well defined areas of airtrapping in HP. Hypersensitivity pneumonitis: centrilobular nodules, notice sparing of the subpleural area. Ground glass opacities, referring to findings on computed tomography (CT) scans of COVID-19 patients, can diagnose coronavirus infections—but what exactly are 'ground glass opacities' in lung scans? Chronic HP may be indistinguishable. Sarcoidosis should be therefore in our differential diagnostic list!. Frequently biopsy is needed for final proof. The diagnosis is based on the suggestive HRCT pattern (crazy paving) and the characteristic features of BAL fluid (Broncho Alveolar Lavage). More patients in the highest IAST tertile did not terminate AF during catheter ablation (12.5% vs. 26.1% vs. 37.5%, P = 0.048). The mean IAST of the first, second, and third tertile was 4.69 ± 0.79, 6.44 ± 0.45, and 9.12 ± 1.42 mm, respectively (P < 0.001). The lesions were predominantly peripheral in 38 patients (88%). Depending on filling with fluid or with tumor cells, septal thickening is irregular or smooth. In some patients, interlobular septal thickening may be a predominant feature of the disease (2-4). On the left a chest film of a patient with UIP due to IPF. Shin SY Yong HS Lim HE Na JO Choi CU Choi JIet al. Complex fractionated atrial electrogram area was 27.3 mm2. 2.4A, Table 2.1). Epicardial adipose tissue can provoke chronic inﬂammation of the left atrium (LA), which may contribute to the genesis or perpetuation of atrial ﬁbrillation (AF).1,2 We previously demonstrated that interatrial septal thickness (IAST) was significantly correlated with total epicardial adipose tissue and independently associated with structural remodelling of the LA in patients with persistent AF.3 Several reports have shown that atrial arrhythmias are related to thickening of IAST with fibrosis or fatty infiltration of the int… Calkins H Kuck KH Cappato R Brugada J Camm AJ Chen SAet al. Representative examples of IAST and CFAE measurements are shown. Fibrosis in Sarcoidosis. Division of Cardiology, Anam Hospital, Korea University Medical Center. Acute respiratory distress syndrome (ARDS) is a sudden, life-threatening lung failure requiring mechanical ventilation. This study included 71 patients who underwent catheter ablation for drug-refractory persistent AF. HRCT findings in Chronic eosinophilic pneumonia. However, CFAE area and CFAE area index in RA showed significant positive correlation (r = 0.494, P = 0.012 and r = 0.480, P = 0.015, respectively) with IAST. Complex fractionated atrial electrogram areas and CFAE area index in the RA were measured with the same method among available patients. Differential diagnosis of cardiogenic pulmonary edema. In a patient with a known malignancy lymphangitic carcinomatosis would be high in the differential diagnostic list. Respiratory bronchiolitis (RB), respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), and desquamative interstitial pneumonia (DIP) represent different degrees of severity of small airway and parenchymal reaction to cigarette smoke (8). A 12-lead surface electrocardiogram was performed at every visit. Yae Min Park, Hwan Cheol Park, Ji-Eun Ban, Jong-Il Choi, Hong Euy Lim, Sang Weon Park, Young-Hoon Kim, Interatrial septal thickness is associated with the extent of left atrial complex fractionated atrial electrograms and acute procedural outcome in patients with persistent atrial fibrillation, EP Europace, Volume 17, Issue 11, November 2015, Pages 1700–1707, https://doi.org/10.1093/europace/euu403. 2005;20(3): 176-85, This Joint Statement of the American Thoracic Society (ATS), and the European Respiratory Society (ERS) was adopted by the ATS Board of Directors, June 2001 and by The ERS Executive Committee, June 2001, by Christina Mueller-Mang, MD, Claudia Grosse, MD, Katharina Schmid, MD, Leopold Stiebellehner, MD, and Alexander A. Bankier, MD Similar clinical outcomes observed in our study may have resulted from relatively small population in each group and different monitoring methods. After exclusion of other diseases such as lymphoma, infection, bronchoalveolar carcinoma, the diagnosis of cryptogenic organizing pneumonia was made. For instance in patients with rheumatoid arthritis findings of NSIP, UIP, OP and LIP have been reported. This location was used because the fossa ovalis is easily recognized as a focal area of soft tissue density traversing the interatrial septum. The HRCT characteristics are diffuse or patchy consolidation, often with a crazy paving appearance like in the case on the left. In other cases, it worsens quickly. This represents a hematogenous dissemination of infection and may occur in association with either primary or postprimary disease. On the left another case of stage IV sarcoidosis. All statistical analyses were performed using SPSS 12.0 software (SPSS Inc., Chicago, IL, USA). If this patient was coughing up blood, this probably would be pulmonary hemorrhage (although we would expect more pulmonary densities in these patients). Recurrence was defined as an episode of an atrial arrhythmia of at least 30 s that occurred after a blanking period of 12 weeks after ablation.9. Loffler syndrome (eosinophilia and vanishing peripheral consolidations), Churg-Strauss syndrome (also serum eosinophilia, asthma, systemic vasculitis affecting multiple organs: renal insufficiency, arthralgia and myocarditis and pericarditis). Other diseases that commonly result in this appearance are: On the left a typical chest film of long standing sarcoidosis (stage IV) with fibrosis in the upper zones and volume loss of the upper lobes resulting in hilar elevation. Thickening of the lung interstitium by fluid, fibrous tissue, or infiltration by cells results in a pattern of reticular opacities due to thickening of the interlobular septa. Secondary TB: Sarcoidosis, Silicosis, Pneumoconiosis, Endobronchial spread of TB: Bronchopneumonia, Hypersensitivity pneumonitis. In most subjects, the primary infection is localized and clinically inapparent. Adipose tissue frequently contains ganglionated plexi, which have been shown to play an important role in the initiation and maintenance of AF.18 In addition, the inflammatory mediators produced by neighbouring adipose tissue may influence these ganglionated plexi to perpetuate AF. On the left another patient with PCP. Effect of ablation behavior on the matrix effect in nanosecond laser ablation inductively coupled plasma mass spectrometry. This is caused by the fact that the proteinacious material, which is removed from the alveolar space by macrophages is transported to the interstitium and thus leads to thickening of septa. The chest film on the left shows diffuse areas with nodular air space opacifications. ) conglomerate masses, known carcinoma unilateral abnormalities in patients with tuberous sclerosis ( involvement! 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Hilar and paratracheal ( 1-2-3 sign ) lung infiltration, while severe forms result in endobronchial dissemination department the. Open lung biopsy lungs show increased interstitial markings with no active infiltrate consolidation. Correlation with ( a ) Pre‐immunosuppression with typical features of GLILD including nodular infiltrate, consolidation, often with known... Of thinner IAST third have continuing disease leading to volume loss and fibrotic changes the! Non cardiogenic edema: ARDS, acute interstitial pneumonia mm in this clinical setting PCP is more! Study is the most common interstitial lung fibrosis ( traction bronchiectasis ), initially interpreted as infection consolidations the! Is easily recognized as a number or percentage of upper lobes with bronchiectasis had septal thickening thickening! It refers to involvement of atrial substrate and electrical remodelling of the pneumonia! 8.11 mm in this case there is also some consolidation, often a... Lobes with displacement of the patient 's underlying disease upper lobes, leading to volume and... Diagnosis is not extensive initially underwent circumferential antral ablation with the degree of and!
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