Charlotte Barbier - Academia.edu (original) (raw)

Papers by Charlotte Barbier

Research paper thumbnail of Placement of Transjugular Intrahepatic Portosystemic Shunt Via the Left Hepatic Vein under Sonographic Guidance in a Patient with Right Hemihepatectomy

Acta Radiologica, 2003

In a patient with refractory ascites after right hemihepatectomy TIPS was created between the lef... more In a patient with refractory ascites after right hemihepatectomy TIPS was created between the left hepatic vein and the left portal vein via a transjugular approach. The puncture was guided only by sonography from the epigastrium. Portosystemic pressure gradient was reduced from 28 to 7 mm Hg and ascites disappeared. This case shows that TIPS can be created with technical and clinical success after right hemihepatectomy as left hepatic vein to left portal vein shunt under sonographic guidance.

Research paper thumbnail of Peritumoral portal enhancement during transarterial chemoembolization: a potential prognostic factor for patients with hepatocellular carcinoma

Acta Radiologica, 2021

Background Tumor response and survival varies in patients treated with transarterial chemoemboliz... more Background Tumor response and survival varies in patients treated with transarterial chemoembolization (TACE) for intermediate stage hepatocellular carcinoma (HCC) and may be associated with several factors. Purpose To evaluate safety and efficacy of TACE in patients with intermediate stage HCC and to identify factors related to tumor response and survival. Material and Methods Consecutive patients with HCC treated with TACE between September 2008 and September 2018 were retrospectively reviewed. Results In 87 patients (71 men; mean age = 68 ± 9 years), 327 TACE treatments were performed (mean = 3/patient; range = 1–12). Mean and median overall survival were 32 and 19 months, respectively. Survival rates at 30 days, one, three, and five years were 99%, 71%, 19%, and 8%, respectively. Objective response (OR) was seen in 84% and disease control (DC) was seen in 92% of the patients. Patients in whom peritumoral portal lipiodol enhancement (PPLE) was seen during TACE had better OR (97 v...

Research paper thumbnail of Long-term prognosis of unrecognized myocardial infarction detected with cardiovascular magnetic resonance in an elderly population

Journal of Cardiovascular Magnetic Resonance, 2016

Background: Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascu... more Background: Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascular magnetic resonance (CMR) constitute a recently defined group whose prognosis has not been fully evaluated. However, increasing evidence indicate that these individuals may be at considerable cardiovascular risk. The aim of the present study was to investigate the prognostic impact of CMR detected UMIs for major adverse cardiac events (MACE) in community living elderly individuals. Methods: Late gadolinium enhancement CMR was performed in 248 randomly chosen 70-year-olds. Individuals with myocardial infarction (MI) scars, with or without a hospital diagnosis of MI were classified as recognized MI (RMI) or UMI, respectively. Medical records and death certificates were scrutinized. MACE was defined as cardiac death, non-fatal MI, a new diagnosis of angina pectoris, or symptom-driven coronary artery revascularization. Results: During follow-up (mean 11 years) MACE occurred in 10 % (n = 18/182) of the individuals without MI scars, in 20 % (n = 11/55) of the individuals with UMI, and in 45 % (n = 5/11) of the individuals with RMI, with a significant difference between the UMI group and the group without MI scars (p = 0.045), and between the RMI group and the group without MI scars (p = 0.0004). Cardiac death and/or non-fatal MI occurred in 15, 5, and 3 of the individuals in the NoMI, UMI, and RMI group respectively. Hazards ratios for MACE adjusted for risk factors and sex were 2.55 (95 % CI 1.20-5.42; p = 0.015) for UMI and 3.28 (95 % CI1.16-9.22; p = 0.025) for RMI. Conclusions: The presence of a CMR detected UMI entailed a more than double risk for MACE in community living 70-year-old individuals.

Research paper thumbnail of Myocardial Scars on MRI Their Prevalence and Possible Impact

Research paper thumbnail of Cardiac troponin I associated with the development of unrecognized myocardial infarctions detected with MRI

Clinical chemistry, 2014

Late enhancement MRI (LE-MRI) and cardiac troponin I (cTnI) are sensitive methods to detect subcl... more Late enhancement MRI (LE-MRI) and cardiac troponin I (cTnI) are sensitive methods to detect subclinical myocardial injury. We sought to investigate the relation between plasma concentrations of cTnI measured with a high-sensitivity assay (hs-cTnI) and the development of unrecognized myocardial infarctions (UMIs) detected with LE-MRI. After approval from the ethics committee and written informed consent were obtained, LE-MRI was performed on 248 randomly selected community-living 70-year-old volunteers and hs-cTnI was determined with a highly sensitive premarket assay. Five years later these individuals were invited to a second LE-MRI, and 176 of them (82 women, 94 men), who did not have a hospital diagnosis of MI, constitute the present study population. LE-MR images were analyzed by 2 radiologists independently and in a consensus reading, blinded to any information on previous disease or assessments. New or larger UMIs were detected in 37 participants during follow-up. Plasma conce...

Research paper thumbnail of Increased collagen turnover in subjects with MRI-detected unrecognized myocardial infarction

Myocardial infarction (MI) causes high morbidity and mortality worldwide and for effective preven... more Myocardial infarction (MI) causes high morbidity and mortality worldwide and for effective prevention and treatment MIs have to be adequately detected.The existence of clinically unrecognized MIs (UMIs) has been known for the past hundred years, but an ultimate tool for their detection has not yet been found. Using persistent Q waves on electrocardiography as a sign of MI, it has been estimated that UMIs constitute at least ¼ of all MIs and have mortality rates similar to those of recognized MIs (RMIs). These estimates are misleading, however, since persistent Q waves do not necessarily represent MIs.The late enhancement technique in magnetic resonance imaging (LE MRI) has been developed over the past decade and accurately determines myocardial viability. The aim of this research was to investigate the prevalence and impact of UMI and RMI in a population-based sample of 70-year-olds, assessed with MRI.Cardiac function and viability were examined with MRI in 259 randomly selected 70-year-old subjects (127 women, 132 men) participating in a larger population-based study (PIVUS). Information on other parameters of cardiovascular disease was obtained and related to the findings.Three methods for segmentation of the left ventricular mass were used in the first 100 subjects; these differed in accuracy and led to differences in systolic function values. In the subsequent 159 examinations one of the segmentation methods was used.The viability images were assessable in 248 subjects (123 women, 125 men). Among these, the prevalence of UMI, 19.8%, definitely exceeded the expectations and UMIs constituted 4/5 of all MIs. The prevalence of RMI was 4.4%. MRI-detected UMIs differed from RMIs in several respects; they were smaller, frequently located inferolaterally, did not appear to be associated with atherosclerosis, and displayed increased collagen turnover. The pathogenesis of these UMIs remains to be investigated, but our observations suggest that they are caused by ischemia. Subjects with UMI showed increased cardiac morbidity, a decreased ejection fraction and an increased left ventricular mass, indicating an increased cardiovascular risk.It is thus important to detect these UMIs, and this is adequately achieved by LE MRI. However, to decide upon prevention and treatment of these UMIs we need to know more about their pathogenesis and prognosis.

Research paper thumbnail of Clinically unrecognized myocardial scars detected by MR are not associated with coronary artery disease

Background: We have previously discovered an unexpected high prevalence of unrecognized myocardia... more Background: We have previously discovered an unexpected high prevalence of unrecognized myocardial infarction (UMI) scars by delayed-enhanced magnetic resonance imaging (DE-MRI) in the general elderly population. We now investigated if those UMIs were associated with coronary artery disease (CAD). Methods: Eighty-eight subjects from the PIVUS study (age 75-years) who had been investigated with DE-MRI (45 with UMI and 43 without DE-MRI-detected scars) underwent coronary computed tomography angiography (CTA) to assess Agatston calcium score and coronary artery stenosis. Of those, 65 also performed an exercise ECG test. Results: No differences were found between the subjects with UMI and the group without DE-MRI-detected scars regarding the number of coronary artery segments with significant stenosis, Agatston calcium score, or degree of ST-depression at the exercise test. Conclusion: DE-MRI-detected UMI scars do not have an increased prevalence of coronary artery stenosis or signs of myocardial ischemia at exercise test when compared to a control group. These findings indicate that UMI scars in general are not related to CAD.

Research paper thumbnail of Imaging Detects Potential Risk Group Myocardial Scars More Frequent Than Expected: Magnetic Resonance

Research paper thumbnail of Prevalence and pathophysiological mechanisms of elevated cardiac troponin I levels in a population-based sample of elderly subjects

European Heart Journal, 2008

To evaluate the prevalence of cardiac troponin I (cTnI) elevation in an elderly community populat... more To evaluate the prevalence of cardiac troponin I (cTnI) elevation in an elderly community population and the association of cTnI levels with cardiovascular risk factors, vascular inflammation, atherosclerosis, cardiac performance, and areas indicative of infarcted myocardium identified by cardiac magnetic resonance imaging. Methods and results cTnI elevation defined as cTnI levels .0.01 mg/L (Access AccuTnI, Beckman Coulter) was found in 21.8% of the study participants (n ¼ 1005). cTnI. 0.01 mg/L was associated with cardiovascular high-risk features, the burden of atherosclerosis in the carotid arteries, left-ventricular mass, and impaired left-ventricular systolic function. No associations were found between cTnI and inflammatory activity, diastolic dysfunction, or myocardial scars. Male gender (OR 1.6; 95% CI 1.1-2.4), ischaemic ECG changes (OR 1.7; 95% CI 1.1-2.7), and NT-pro-brain natriuretic peptide levels (OR 1.4; 95% CI 1.1-1.7) independently predicted cTnI. 0.01 mg/L. cTnI. 0.01 mg/L correlated also to an increased cardiovascular risk according to the Framingham risk score. Conclusion cTnI. 0.01 mg/L is relatively common in elderly subjects and is associated with cardiovascular high-risk features and impaired cardiac performance. Cardiac troponin determined by a highly sensitive assay might thus serve as an instrument for the identification of subjects at high cardiovascular risk in general populations.

Research paper thumbnail of Total atherosclerotic burden by whole body magnetic resonance angiography predicts major adverse cardiovascular events

Atherosclerosis, 2013

Objective: The purpose of the present study was to investigate the relationship between the Total... more Objective: The purpose of the present study was to investigate the relationship between the Total Atherosclerotic Score (TAS), a measurement of the overall atherosclerotic burden of the arterial tree by whole body magnetic resonance angiography (WBMRA), and the risk of major adverse cardiovascular events (MACE), defined as cardiac death, myocardial infarction, stroke and/or coronary revascularization, assuming that TAS predicts MACE. Methods and results: 305 randomly selected 70 year-old subjects (47% women) underwent WBMRA. Their atherosclerotic burden was evaluated and TAS > 0, that is atherosclerotic changes, were found in 68% of subjects. During follow-up (mean 4.8 years), MACE occurred in 25 subjects (8.2%). Adjusting for multiple risk factors, TAS was associated with MACE (OR 8.86 for any degree of vessel lumen abnormality, 95%CI 1.14e69.11, p ¼ 0.037). In addition, TAS improved discrimination and reclassification when added to the Framingham risk score (FRS), and ROC (Receiver Operator Curve) increased from 0.681 to 0.750 (p ¼ 0.0421). Conclusion: In a population-based sample of 70 year old men and women WBMRA, with TAS, predicted MACE independently of major cardiovascular risk factors.

Research paper thumbnail of Apolipoprotein B/A-I ratio related to visceral but not to subcutaneous adipose tissue in elderly Swedes

Atherosclerosis, 2010

Objective: To investigate whether the amount of visceral (VAT) or subcutaneous adipose tissue (SA... more Objective: To investigate whether the amount of visceral (VAT) or subcutaneous adipose tissue (SAT) independently of the other can determine the apolipoprotein (apo)B/A-I ratio. Methods: VAT and SAT areas were assessed using magnetic resonance imaging in 247 randomly selected 70-year-old men and women who did not use lipid-lowering drugs. Their adipose tissue areas were compared to their apoB and apo A-I levels and to their apoB/A-I ratios. Results: The VAT area and the gender were significantly related to the apoB/A-I ratio whereas the SAT area was not. There was a positive relationship between the VAT area and the apoB/A-I ratio. Conclusion: A positive relationship was established between the amount of VAT and the apoB/A-I ratio, whereas there was no relationship between the amount of SAT and the apoB/A-I ratio. This observation supports the notion that VAT is metabolically active.

Research paper thumbnail of Signal intensity of myocardial scars at delayed-enhanced mri

Acta Radiologica, 2009

Background: Traditionally, unrecognized myocardial infarction (UMI) is defined as the appearance,... more Background: Traditionally, unrecognized myocardial infarction (UMI) is defined as the appearance, in a non-acute setting, of a new diagnostic Q wave. In the recent past, delayed-enhanced magnetic resonance imaging (DE-MRI) has provided a new imaging method for evaluating myocardial viability and to detect myocardial scars. Purpose: To investigate differences in tissue characteristics between UMI and recognized myocardial infarction (RMI) scars, by assessing the signal intensity (SI) detected by DE-MRI. Material and Methods: A randomized subgroup of 259 subjects from the Prospective Investigation of the Vasculature of Uppsala Seniors (PIVUS) study was submitted to cardiac magnetic resonance imaging (MRI). DE-MRI-detected myocardial scars were divided in two groups, UMI and RMI, according to the hospital medical records. The scars detected by DE-MRI were analyzed by measuring SI ratio of scar tissue to normal myocardium. Results: The mean SI ratio in the UMI group (4.5±3.0, mean±SD) w...

Research paper thumbnail of Prevalence of Unrecognized Myocardial Infarction Detected With Magnetic Resonance Imaging and its Relationship to Cerebral Ischemic Lesions in Both Sexes

Journal of the American College of Cardiology, 2011

The purpose of this study was to investigate the prevalence of unrecognized myocardial infarction... more The purpose of this study was to investigate the prevalence of unrecognized myocardial infarction (UMI) detected with magnetic resonance imaging (MRI) and whether it is related to cerebral ischemic lesions on MRI in an elderly population-based cohort. Background There is a correlation between stroke and recognized myocardial infarction (RMI) and between stroke and UMI detected with electrocardiography, whereas the prevalence of stroke in subjects with MRI-detected UMI is unknown. Methods Cerebral MRI and cardiac late-enhancement MRI were performed on 394 randomly selected 75-year-old subjects (188 women, 206 men). Images were assessed for cerebral ischemic lesions and myocardial infarction (MI) scars. Medical records were scrutinized. Subjects with MI scars, with or without a hospital diagnosis of MI, were classified as RMI or UMI, respectively. Results UMIs were found in 120 subjects (30%) and RMIs in 21 (5%). The prevalence of UMIs (p ϭ 0.004) and RMIs (p ϭ 0.02) was greater in men than in women. Men with RMI displayed an increased prevalence of cortical and lacunar cerebral infarctions, whereas women with UMI more frequently had cortical cerebral infarctions (p ϭ 0.003). Conclusions MI scars are more frequent in men than in women at 75 years of age. The prevalence of RMI is related to that of cerebral infarctions.

Research paper thumbnail of Unrecognized myocardial scars detected by delayed–enhanced MRI are associated with increased levels of NT-proBNP

Coronary Artery Disease, 2011

Objectives Patients with unrecognized myocardial infarction (UMI) scars detected by delayed-enhan... more Objectives Patients with unrecognized myocardial infarction (UMI) scars detected by delayed-enhanced magnetic resonance imaging (DE-MRI) have a decreased left ventricular ejection fraction and an increased left ventricular mass. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of heart failure, and troponin I (TnI) is a marker of myocardial injury. The primary aim of this study was to investigate whether NT-proBNP plasma levels (in addition to ejection fraction) differed in patients with UMI scars compared with normal participants. The second aim was to compare whether the TnI levels differed in those two groups. Methods Data from the Prospective Investigation of Vasculature in Uppsala Seniors study were used. The participants who had undergone cardiac MRI were included in this study (n = 248). Patients were divided into three groups depending on the existence of a myocardial infarction (MI) scar in DE-MRI and their earlier history of MI. In all the patients, a peripheral blood sample was collected and the plasma levels of NT-proBNP and TnI were determined. Results Patients with UMI had higher plasma levels of NT-proBNP (median 140.2 ng/l; 25th-75th percentiles: 79-225.5) than no-MI participants (median 94.9 ng/l; 25th-75th percentiles: 59.2-144.2; P = 0.01) and lower levels than patients with recognized MI (median 310.4 ng/l; 25th-75th percentiles: 122.6-446.5; P = 0.02). Plasma TnI values did not differ among the three groups. Conclusion Patients with UMI scars detected by DE-MRI have increased plasma levels of NT-proBNP that is known to correlate with an increased risk of future cardiovascular adverse events. Coron Artery Dis

Research paper thumbnail of Upsala Journal of Medical Sciences. 2011; 116: 258–264 ORIGINAL ARTICLE

Several sources of error in estimation of left ventricular mass with M-mode echocardiography in e... more Several sources of error in estimation of left ventricular mass with M-mode echocardiography in elderly subjects

Research paper thumbnail of Myocardial Scars More Frequent Than Expected

Journal of the American College of Cardiology, 2006

The aim of this study was to investigate the prevalence of clinically recognized myocardial infar... more The aim of this study was to investigate the prevalence of clinically recognized myocardial infarctions (RMIs) and unrecognized myocardial infarctions (UMIs) in 70-year-old subjects, assessed with magnetic resonance imaging (MRI), and to relate the findings to cardiac function and morbidity. BACKGROUND Late enhancement MRI identifies myocardial scars and thereby has the potential to detect UMI. METHODS Cardiac MRI was performed on 259 randomly chosen 70-year-old subjects. Late enhancement and cine sequences were acquired, and the ejection fraction and left ventricular (LV) mass were calculated. Late enhancement involving the subendocardial layer was considered to represent myocardial infarction (MI) scars, and their volumes were calculated. Information on cardiac morbidity and risk factors was collected from medical records and from a health examination. Subjects with MI scars, with or without a hospital diagnosis of MI were classified as RMI or UMI, respectively. RESULTS The images from 248 subjects (123 women, 125 men) were assessable. Myocardial infarction scars were found in 60 subjects (24.2%), in 49 of whom (19.8%) they were UMIs. The volumes of the UMIs were significantly smaller than those of the RMIs. There was an increased frequency of chest pain symptoms among the subjects with UMI or RMI compared with those without MI scars. Ejection fraction was significantly lower and LV mass significantly larger in the subjects with UMI or RMI than in those without MI scars. CONCLUSIONS Unrecognized MI detected with MRI was more frequent than expected in 70-year-old subjects. The subjects displaying these UMIs may represent a previously unknown potential risk group for future cardiovascular events.

Research paper thumbnail of Limitations and Possibilities of Transarterial Chemotherapeutic Treatment of Hepatocellular Carcinoma

International Journal of Molecular Sciences

Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced c... more Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced cirrhosis are poor, HCC is often detected in a stage where transarterial chemoembolization (TACE) is the best treatment option, even though it provides a poor survival gain. Despite having been used worldwide for several decades, TACE still has many limitations. First, there is a vast heterogeneity in the cellular composition and metabolism of HCCs as well as in the patient population, which renders it difficult to identify patients who would benefit from TACE. Often the delivered drug does not penetrate sufficiently selectively and deeply into the tumour and the drug delivery system is not releasing the drug at an optimal clinical rate. In addition, therapeutic effectiveness is limited by the crosstalk between the tumour cells and components of the cirrhotic tumour microenvironment. To improve this widely used treatment of one of our most common and deadly cancers, we need to better unde...

Research paper thumbnail of The Exactness of Left Ventricular Segmentation in Cine Magnetic Resonance Imaging and Its Impact on Systolic Function Values

Acta Radiologica, 2007

Purpose: To evaluate the impact of exactness of the segmentation of the left ventricle (LV), usin... more Purpose: To evaluate the impact of exactness of the segmentation of the left ventricle (LV), using cine magnetic resonance imaging (MRI). Material and methods: Steady-state free-precession cine MRI was performed on 100 randomly selected subjects. Myocardial borders were outlined on short-axis images using three methods: method 1 was computer assisted, excluding papillary muscles from the left ventricular mass (LVM); method 2 was similar but included papillary muscles; and method 3 was manually traced including papillary muscles. LV end-systolic (ES) and end-diastolic (ED) masses and volumes, ejection fraction (EF), stroke volume (SV), and cardiac output (CO) were calculated from these measurements. The difference between the ES and ED LVM was used to estimate the exactness of the methods. Results: Method 3 was the most exact, and method 1 was the least exact. The three methods generated differing EF, SV, and CO measurements. With an ES–ED LVM difference exceeding 20 g, the mean SV m...

Research paper thumbnail of Several sources of error in estimation of left ventricular mass with M-mode echocardiography in elderly subjects

Upsala Journal of Medical Sciences, 2011

Introduction. M-mode echocardiography estimates of the left ventricular mass (LVM) were greater t... more Introduction. M-mode echocardiography estimates of the left ventricular mass (LVM) were greater than magnetic resonance imaging (MRI) estimates. There are substantial differences between the methods both in the means of measuring and the calculation formula. The aim of this study was to investigate whether any difference in estimates of LVM between M-mode echocardiography and MRI is due to the means of measuring or to the calculation formula, using MRI as the gold standard. Material and methods. M-mode echocardiography and MRI were performed on 229 randomly selected 70-year-old communityliving subjects. LVM was calculated from echocardiography (LVM echo) and from MRI (LVM MRI) measurements using standard techniques. Additionally LVM was calculated with the echocardiography formula from echo-mimicking measurements made on MR images (LVM MRI/ASE). Results. There were significant differences between all three LVM estimates in women, in men, and in the entire population. Echocardiography estimated LVM to be larger than did MRI, and the LVM MRI/ASE estimate was larger than the LVM MRI. The difference between LVM MRI and LVM MRI/ASE was larger than the difference between LVM echo and LVM MRI/ASE. There was a low correlation between LVM echo and LVM MRI (R 2 = 0.46) as well as between LVM MRI/ASE and LVM MRI (R 2 = 0.65). Conclusion. The means of measuring and the calculation formula both independently add to the error in LVM estimation with M-mode echocardiography. The error of the calculation formula seems to be greater than the error of the means of measuring in a population of community-living elderly men and women.

Research paper thumbnail of Cardiac Troponin I Predicts the Development of Unrecognized Myocardial Infarctions Detected with Magnetic Resonance Imaging

PURPOSE To investigate whether plasma levels of cardiac troponin I measured with a high-sensitivi... more PURPOSE To investigate whether plasma levels of cardiac troponin I measured with a high-sensitivity assay (hs-cTnI) could predict the development of unrecognized myocardial infarctions (UMIs) detected with late enhancement magnetic resonance imaging (LE-MRI). METHOD AND MATERIALS LE-MRI was performed on 248 randomly selected community-living 70-year-old subjects and hs-cTnI was determined with a highly sensitive premarket assay. Five years later the subjects were invited to a second LE-MRI, and 143 of them (68 women, 75 men) who were free from myocardial scars at 70 years of age and did not have a hospital diagnosis of MI, constitute the present study population. LE involving the subendocardial layer was considered an MI scar. RESULTS New UMIs were detected in 37 subjects during follow-up. Plasma levels of hs-cTnI at 70 years of age, which were mainly within what is considered to be the normal range, were related to new UMIs at 75 years of age with an adjusted Odds Ratio (OR) of 1.7...

Research paper thumbnail of Placement of Transjugular Intrahepatic Portosystemic Shunt Via the Left Hepatic Vein under Sonographic Guidance in a Patient with Right Hemihepatectomy

Acta Radiologica, 2003

In a patient with refractory ascites after right hemihepatectomy TIPS was created between the lef... more In a patient with refractory ascites after right hemihepatectomy TIPS was created between the left hepatic vein and the left portal vein via a transjugular approach. The puncture was guided only by sonography from the epigastrium. Portosystemic pressure gradient was reduced from 28 to 7 mm Hg and ascites disappeared. This case shows that TIPS can be created with technical and clinical success after right hemihepatectomy as left hepatic vein to left portal vein shunt under sonographic guidance.

Research paper thumbnail of Peritumoral portal enhancement during transarterial chemoembolization: a potential prognostic factor for patients with hepatocellular carcinoma

Acta Radiologica, 2021

Background Tumor response and survival varies in patients treated with transarterial chemoemboliz... more Background Tumor response and survival varies in patients treated with transarterial chemoembolization (TACE) for intermediate stage hepatocellular carcinoma (HCC) and may be associated with several factors. Purpose To evaluate safety and efficacy of TACE in patients with intermediate stage HCC and to identify factors related to tumor response and survival. Material and Methods Consecutive patients with HCC treated with TACE between September 2008 and September 2018 were retrospectively reviewed. Results In 87 patients (71 men; mean age = 68 ± 9 years), 327 TACE treatments were performed (mean = 3/patient; range = 1–12). Mean and median overall survival were 32 and 19 months, respectively. Survival rates at 30 days, one, three, and five years were 99%, 71%, 19%, and 8%, respectively. Objective response (OR) was seen in 84% and disease control (DC) was seen in 92% of the patients. Patients in whom peritumoral portal lipiodol enhancement (PPLE) was seen during TACE had better OR (97 v...

Research paper thumbnail of Long-term prognosis of unrecognized myocardial infarction detected with cardiovascular magnetic resonance in an elderly population

Journal of Cardiovascular Magnetic Resonance, 2016

Background: Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascu... more Background: Individuals with unrecognized myocardial infarctions (UMIs) detected with cardiovascular magnetic resonance (CMR) constitute a recently defined group whose prognosis has not been fully evaluated. However, increasing evidence indicate that these individuals may be at considerable cardiovascular risk. The aim of the present study was to investigate the prognostic impact of CMR detected UMIs for major adverse cardiac events (MACE) in community living elderly individuals. Methods: Late gadolinium enhancement CMR was performed in 248 randomly chosen 70-year-olds. Individuals with myocardial infarction (MI) scars, with or without a hospital diagnosis of MI were classified as recognized MI (RMI) or UMI, respectively. Medical records and death certificates were scrutinized. MACE was defined as cardiac death, non-fatal MI, a new diagnosis of angina pectoris, or symptom-driven coronary artery revascularization. Results: During follow-up (mean 11 years) MACE occurred in 10 % (n = 18/182) of the individuals without MI scars, in 20 % (n = 11/55) of the individuals with UMI, and in 45 % (n = 5/11) of the individuals with RMI, with a significant difference between the UMI group and the group without MI scars (p = 0.045), and between the RMI group and the group without MI scars (p = 0.0004). Cardiac death and/or non-fatal MI occurred in 15, 5, and 3 of the individuals in the NoMI, UMI, and RMI group respectively. Hazards ratios for MACE adjusted for risk factors and sex were 2.55 (95 % CI 1.20-5.42; p = 0.015) for UMI and 3.28 (95 % CI1.16-9.22; p = 0.025) for RMI. Conclusions: The presence of a CMR detected UMI entailed a more than double risk for MACE in community living 70-year-old individuals.

Research paper thumbnail of Myocardial Scars on MRI Their Prevalence and Possible Impact

Research paper thumbnail of Cardiac troponin I associated with the development of unrecognized myocardial infarctions detected with MRI

Clinical chemistry, 2014

Late enhancement MRI (LE-MRI) and cardiac troponin I (cTnI) are sensitive methods to detect subcl... more Late enhancement MRI (LE-MRI) and cardiac troponin I (cTnI) are sensitive methods to detect subclinical myocardial injury. We sought to investigate the relation between plasma concentrations of cTnI measured with a high-sensitivity assay (hs-cTnI) and the development of unrecognized myocardial infarctions (UMIs) detected with LE-MRI. After approval from the ethics committee and written informed consent were obtained, LE-MRI was performed on 248 randomly selected community-living 70-year-old volunteers and hs-cTnI was determined with a highly sensitive premarket assay. Five years later these individuals were invited to a second LE-MRI, and 176 of them (82 women, 94 men), who did not have a hospital diagnosis of MI, constitute the present study population. LE-MR images were analyzed by 2 radiologists independently and in a consensus reading, blinded to any information on previous disease or assessments. New or larger UMIs were detected in 37 participants during follow-up. Plasma conce...

Research paper thumbnail of Increased collagen turnover in subjects with MRI-detected unrecognized myocardial infarction

Myocardial infarction (MI) causes high morbidity and mortality worldwide and for effective preven... more Myocardial infarction (MI) causes high morbidity and mortality worldwide and for effective prevention and treatment MIs have to be adequately detected.The existence of clinically unrecognized MIs (UMIs) has been known for the past hundred years, but an ultimate tool for their detection has not yet been found. Using persistent Q waves on electrocardiography as a sign of MI, it has been estimated that UMIs constitute at least ¼ of all MIs and have mortality rates similar to those of recognized MIs (RMIs). These estimates are misleading, however, since persistent Q waves do not necessarily represent MIs.The late enhancement technique in magnetic resonance imaging (LE MRI) has been developed over the past decade and accurately determines myocardial viability. The aim of this research was to investigate the prevalence and impact of UMI and RMI in a population-based sample of 70-year-olds, assessed with MRI.Cardiac function and viability were examined with MRI in 259 randomly selected 70-year-old subjects (127 women, 132 men) participating in a larger population-based study (PIVUS). Information on other parameters of cardiovascular disease was obtained and related to the findings.Three methods for segmentation of the left ventricular mass were used in the first 100 subjects; these differed in accuracy and led to differences in systolic function values. In the subsequent 159 examinations one of the segmentation methods was used.The viability images were assessable in 248 subjects (123 women, 125 men). Among these, the prevalence of UMI, 19.8%, definitely exceeded the expectations and UMIs constituted 4/5 of all MIs. The prevalence of RMI was 4.4%. MRI-detected UMIs differed from RMIs in several respects; they were smaller, frequently located inferolaterally, did not appear to be associated with atherosclerosis, and displayed increased collagen turnover. The pathogenesis of these UMIs remains to be investigated, but our observations suggest that they are caused by ischemia. Subjects with UMI showed increased cardiac morbidity, a decreased ejection fraction and an increased left ventricular mass, indicating an increased cardiovascular risk.It is thus important to detect these UMIs, and this is adequately achieved by LE MRI. However, to decide upon prevention and treatment of these UMIs we need to know more about their pathogenesis and prognosis.

Research paper thumbnail of Clinically unrecognized myocardial scars detected by MR are not associated with coronary artery disease

Background: We have previously discovered an unexpected high prevalence of unrecognized myocardia... more Background: We have previously discovered an unexpected high prevalence of unrecognized myocardial infarction (UMI) scars by delayed-enhanced magnetic resonance imaging (DE-MRI) in the general elderly population. We now investigated if those UMIs were associated with coronary artery disease (CAD). Methods: Eighty-eight subjects from the PIVUS study (age 75-years) who had been investigated with DE-MRI (45 with UMI and 43 without DE-MRI-detected scars) underwent coronary computed tomography angiography (CTA) to assess Agatston calcium score and coronary artery stenosis. Of those, 65 also performed an exercise ECG test. Results: No differences were found between the subjects with UMI and the group without DE-MRI-detected scars regarding the number of coronary artery segments with significant stenosis, Agatston calcium score, or degree of ST-depression at the exercise test. Conclusion: DE-MRI-detected UMI scars do not have an increased prevalence of coronary artery stenosis or signs of myocardial ischemia at exercise test when compared to a control group. These findings indicate that UMI scars in general are not related to CAD.

Research paper thumbnail of Imaging Detects Potential Risk Group Myocardial Scars More Frequent Than Expected: Magnetic Resonance

Research paper thumbnail of Prevalence and pathophysiological mechanisms of elevated cardiac troponin I levels in a population-based sample of elderly subjects

European Heart Journal, 2008

To evaluate the prevalence of cardiac troponin I (cTnI) elevation in an elderly community populat... more To evaluate the prevalence of cardiac troponin I (cTnI) elevation in an elderly community population and the association of cTnI levels with cardiovascular risk factors, vascular inflammation, atherosclerosis, cardiac performance, and areas indicative of infarcted myocardium identified by cardiac magnetic resonance imaging. Methods and results cTnI elevation defined as cTnI levels .0.01 mg/L (Access AccuTnI, Beckman Coulter) was found in 21.8% of the study participants (n ¼ 1005). cTnI. 0.01 mg/L was associated with cardiovascular high-risk features, the burden of atherosclerosis in the carotid arteries, left-ventricular mass, and impaired left-ventricular systolic function. No associations were found between cTnI and inflammatory activity, diastolic dysfunction, or myocardial scars. Male gender (OR 1.6; 95% CI 1.1-2.4), ischaemic ECG changes (OR 1.7; 95% CI 1.1-2.7), and NT-pro-brain natriuretic peptide levels (OR 1.4; 95% CI 1.1-1.7) independently predicted cTnI. 0.01 mg/L. cTnI. 0.01 mg/L correlated also to an increased cardiovascular risk according to the Framingham risk score. Conclusion cTnI. 0.01 mg/L is relatively common in elderly subjects and is associated with cardiovascular high-risk features and impaired cardiac performance. Cardiac troponin determined by a highly sensitive assay might thus serve as an instrument for the identification of subjects at high cardiovascular risk in general populations.

Research paper thumbnail of Total atherosclerotic burden by whole body magnetic resonance angiography predicts major adverse cardiovascular events

Atherosclerosis, 2013

Objective: The purpose of the present study was to investigate the relationship between the Total... more Objective: The purpose of the present study was to investigate the relationship between the Total Atherosclerotic Score (TAS), a measurement of the overall atherosclerotic burden of the arterial tree by whole body magnetic resonance angiography (WBMRA), and the risk of major adverse cardiovascular events (MACE), defined as cardiac death, myocardial infarction, stroke and/or coronary revascularization, assuming that TAS predicts MACE. Methods and results: 305 randomly selected 70 year-old subjects (47% women) underwent WBMRA. Their atherosclerotic burden was evaluated and TAS > 0, that is atherosclerotic changes, were found in 68% of subjects. During follow-up (mean 4.8 years), MACE occurred in 25 subjects (8.2%). Adjusting for multiple risk factors, TAS was associated with MACE (OR 8.86 for any degree of vessel lumen abnormality, 95%CI 1.14e69.11, p ¼ 0.037). In addition, TAS improved discrimination and reclassification when added to the Framingham risk score (FRS), and ROC (Receiver Operator Curve) increased from 0.681 to 0.750 (p ¼ 0.0421). Conclusion: In a population-based sample of 70 year old men and women WBMRA, with TAS, predicted MACE independently of major cardiovascular risk factors.

Research paper thumbnail of Apolipoprotein B/A-I ratio related to visceral but not to subcutaneous adipose tissue in elderly Swedes

Atherosclerosis, 2010

Objective: To investigate whether the amount of visceral (VAT) or subcutaneous adipose tissue (SA... more Objective: To investigate whether the amount of visceral (VAT) or subcutaneous adipose tissue (SAT) independently of the other can determine the apolipoprotein (apo)B/A-I ratio. Methods: VAT and SAT areas were assessed using magnetic resonance imaging in 247 randomly selected 70-year-old men and women who did not use lipid-lowering drugs. Their adipose tissue areas were compared to their apoB and apo A-I levels and to their apoB/A-I ratios. Results: The VAT area and the gender were significantly related to the apoB/A-I ratio whereas the SAT area was not. There was a positive relationship between the VAT area and the apoB/A-I ratio. Conclusion: A positive relationship was established between the amount of VAT and the apoB/A-I ratio, whereas there was no relationship between the amount of SAT and the apoB/A-I ratio. This observation supports the notion that VAT is metabolically active.

Research paper thumbnail of Signal intensity of myocardial scars at delayed-enhanced mri

Acta Radiologica, 2009

Background: Traditionally, unrecognized myocardial infarction (UMI) is defined as the appearance,... more Background: Traditionally, unrecognized myocardial infarction (UMI) is defined as the appearance, in a non-acute setting, of a new diagnostic Q wave. In the recent past, delayed-enhanced magnetic resonance imaging (DE-MRI) has provided a new imaging method for evaluating myocardial viability and to detect myocardial scars. Purpose: To investigate differences in tissue characteristics between UMI and recognized myocardial infarction (RMI) scars, by assessing the signal intensity (SI) detected by DE-MRI. Material and Methods: A randomized subgroup of 259 subjects from the Prospective Investigation of the Vasculature of Uppsala Seniors (PIVUS) study was submitted to cardiac magnetic resonance imaging (MRI). DE-MRI-detected myocardial scars were divided in two groups, UMI and RMI, according to the hospital medical records. The scars detected by DE-MRI were analyzed by measuring SI ratio of scar tissue to normal myocardium. Results: The mean SI ratio in the UMI group (4.5±3.0, mean±SD) w...

Research paper thumbnail of Prevalence of Unrecognized Myocardial Infarction Detected With Magnetic Resonance Imaging and its Relationship to Cerebral Ischemic Lesions in Both Sexes

Journal of the American College of Cardiology, 2011

The purpose of this study was to investigate the prevalence of unrecognized myocardial infarction... more The purpose of this study was to investigate the prevalence of unrecognized myocardial infarction (UMI) detected with magnetic resonance imaging (MRI) and whether it is related to cerebral ischemic lesions on MRI in an elderly population-based cohort. Background There is a correlation between stroke and recognized myocardial infarction (RMI) and between stroke and UMI detected with electrocardiography, whereas the prevalence of stroke in subjects with MRI-detected UMI is unknown. Methods Cerebral MRI and cardiac late-enhancement MRI were performed on 394 randomly selected 75-year-old subjects (188 women, 206 men). Images were assessed for cerebral ischemic lesions and myocardial infarction (MI) scars. Medical records were scrutinized. Subjects with MI scars, with or without a hospital diagnosis of MI, were classified as RMI or UMI, respectively. Results UMIs were found in 120 subjects (30%) and RMIs in 21 (5%). The prevalence of UMIs (p ϭ 0.004) and RMIs (p ϭ 0.02) was greater in men than in women. Men with RMI displayed an increased prevalence of cortical and lacunar cerebral infarctions, whereas women with UMI more frequently had cortical cerebral infarctions (p ϭ 0.003). Conclusions MI scars are more frequent in men than in women at 75 years of age. The prevalence of RMI is related to that of cerebral infarctions.

Research paper thumbnail of Unrecognized myocardial scars detected by delayed–enhanced MRI are associated with increased levels of NT-proBNP

Coronary Artery Disease, 2011

Objectives Patients with unrecognized myocardial infarction (UMI) scars detected by delayed-enhan... more Objectives Patients with unrecognized myocardial infarction (UMI) scars detected by delayed-enhanced magnetic resonance imaging (DE-MRI) have a decreased left ventricular ejection fraction and an increased left ventricular mass. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of heart failure, and troponin I (TnI) is a marker of myocardial injury. The primary aim of this study was to investigate whether NT-proBNP plasma levels (in addition to ejection fraction) differed in patients with UMI scars compared with normal participants. The second aim was to compare whether the TnI levels differed in those two groups. Methods Data from the Prospective Investigation of Vasculature in Uppsala Seniors study were used. The participants who had undergone cardiac MRI were included in this study (n = 248). Patients were divided into three groups depending on the existence of a myocardial infarction (MI) scar in DE-MRI and their earlier history of MI. In all the patients, a peripheral blood sample was collected and the plasma levels of NT-proBNP and TnI were determined. Results Patients with UMI had higher plasma levels of NT-proBNP (median 140.2 ng/l; 25th-75th percentiles: 79-225.5) than no-MI participants (median 94.9 ng/l; 25th-75th percentiles: 59.2-144.2; P = 0.01) and lower levels than patients with recognized MI (median 310.4 ng/l; 25th-75th percentiles: 122.6-446.5; P = 0.02). Plasma TnI values did not differ among the three groups. Conclusion Patients with UMI scars detected by DE-MRI have increased plasma levels of NT-proBNP that is known to correlate with an increased risk of future cardiovascular adverse events. Coron Artery Dis

Research paper thumbnail of Upsala Journal of Medical Sciences. 2011; 116: 258–264 ORIGINAL ARTICLE

Several sources of error in estimation of left ventricular mass with M-mode echocardiography in e... more Several sources of error in estimation of left ventricular mass with M-mode echocardiography in elderly subjects

Research paper thumbnail of Myocardial Scars More Frequent Than Expected

Journal of the American College of Cardiology, 2006

The aim of this study was to investigate the prevalence of clinically recognized myocardial infar... more The aim of this study was to investigate the prevalence of clinically recognized myocardial infarctions (RMIs) and unrecognized myocardial infarctions (UMIs) in 70-year-old subjects, assessed with magnetic resonance imaging (MRI), and to relate the findings to cardiac function and morbidity. BACKGROUND Late enhancement MRI identifies myocardial scars and thereby has the potential to detect UMI. METHODS Cardiac MRI was performed on 259 randomly chosen 70-year-old subjects. Late enhancement and cine sequences were acquired, and the ejection fraction and left ventricular (LV) mass were calculated. Late enhancement involving the subendocardial layer was considered to represent myocardial infarction (MI) scars, and their volumes were calculated. Information on cardiac morbidity and risk factors was collected from medical records and from a health examination. Subjects with MI scars, with or without a hospital diagnosis of MI were classified as RMI or UMI, respectively. RESULTS The images from 248 subjects (123 women, 125 men) were assessable. Myocardial infarction scars were found in 60 subjects (24.2%), in 49 of whom (19.8%) they were UMIs. The volumes of the UMIs were significantly smaller than those of the RMIs. There was an increased frequency of chest pain symptoms among the subjects with UMI or RMI compared with those without MI scars. Ejection fraction was significantly lower and LV mass significantly larger in the subjects with UMI or RMI than in those without MI scars. CONCLUSIONS Unrecognized MI detected with MRI was more frequent than expected in 70-year-old subjects. The subjects displaying these UMIs may represent a previously unknown potential risk group for future cardiovascular events.

Research paper thumbnail of Limitations and Possibilities of Transarterial Chemotherapeutic Treatment of Hepatocellular Carcinoma

International Journal of Molecular Sciences

Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced c... more Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced cirrhosis are poor, HCC is often detected in a stage where transarterial chemoembolization (TACE) is the best treatment option, even though it provides a poor survival gain. Despite having been used worldwide for several decades, TACE still has many limitations. First, there is a vast heterogeneity in the cellular composition and metabolism of HCCs as well as in the patient population, which renders it difficult to identify patients who would benefit from TACE. Often the delivered drug does not penetrate sufficiently selectively and deeply into the tumour and the drug delivery system is not releasing the drug at an optimal clinical rate. In addition, therapeutic effectiveness is limited by the crosstalk between the tumour cells and components of the cirrhotic tumour microenvironment. To improve this widely used treatment of one of our most common and deadly cancers, we need to better unde...

Research paper thumbnail of The Exactness of Left Ventricular Segmentation in Cine Magnetic Resonance Imaging and Its Impact on Systolic Function Values

Acta Radiologica, 2007

Purpose: To evaluate the impact of exactness of the segmentation of the left ventricle (LV), usin... more Purpose: To evaluate the impact of exactness of the segmentation of the left ventricle (LV), using cine magnetic resonance imaging (MRI). Material and methods: Steady-state free-precession cine MRI was performed on 100 randomly selected subjects. Myocardial borders were outlined on short-axis images using three methods: method 1 was computer assisted, excluding papillary muscles from the left ventricular mass (LVM); method 2 was similar but included papillary muscles; and method 3 was manually traced including papillary muscles. LV end-systolic (ES) and end-diastolic (ED) masses and volumes, ejection fraction (EF), stroke volume (SV), and cardiac output (CO) were calculated from these measurements. The difference between the ES and ED LVM was used to estimate the exactness of the methods. Results: Method 3 was the most exact, and method 1 was the least exact. The three methods generated differing EF, SV, and CO measurements. With an ES–ED LVM difference exceeding 20 g, the mean SV m...

Research paper thumbnail of Several sources of error in estimation of left ventricular mass with M-mode echocardiography in elderly subjects

Upsala Journal of Medical Sciences, 2011

Introduction. M-mode echocardiography estimates of the left ventricular mass (LVM) were greater t... more Introduction. M-mode echocardiography estimates of the left ventricular mass (LVM) were greater than magnetic resonance imaging (MRI) estimates. There are substantial differences between the methods both in the means of measuring and the calculation formula. The aim of this study was to investigate whether any difference in estimates of LVM between M-mode echocardiography and MRI is due to the means of measuring or to the calculation formula, using MRI as the gold standard. Material and methods. M-mode echocardiography and MRI were performed on 229 randomly selected 70-year-old communityliving subjects. LVM was calculated from echocardiography (LVM echo) and from MRI (LVM MRI) measurements using standard techniques. Additionally LVM was calculated with the echocardiography formula from echo-mimicking measurements made on MR images (LVM MRI/ASE). Results. There were significant differences between all three LVM estimates in women, in men, and in the entire population. Echocardiography estimated LVM to be larger than did MRI, and the LVM MRI/ASE estimate was larger than the LVM MRI. The difference between LVM MRI and LVM MRI/ASE was larger than the difference between LVM echo and LVM MRI/ASE. There was a low correlation between LVM echo and LVM MRI (R 2 = 0.46) as well as between LVM MRI/ASE and LVM MRI (R 2 = 0.65). Conclusion. The means of measuring and the calculation formula both independently add to the error in LVM estimation with M-mode echocardiography. The error of the calculation formula seems to be greater than the error of the means of measuring in a population of community-living elderly men and women.

Research paper thumbnail of Cardiac Troponin I Predicts the Development of Unrecognized Myocardial Infarctions Detected with Magnetic Resonance Imaging

PURPOSE To investigate whether plasma levels of cardiac troponin I measured with a high-sensitivi... more PURPOSE To investigate whether plasma levels of cardiac troponin I measured with a high-sensitivity assay (hs-cTnI) could predict the development of unrecognized myocardial infarctions (UMIs) detected with late enhancement magnetic resonance imaging (LE-MRI). METHOD AND MATERIALS LE-MRI was performed on 248 randomly selected community-living 70-year-old subjects and hs-cTnI was determined with a highly sensitive premarket assay. Five years later the subjects were invited to a second LE-MRI, and 143 of them (68 women, 75 men) who were free from myocardial scars at 70 years of age and did not have a hospital diagnosis of MI, constitute the present study population. LE involving the subendocardial layer was considered an MI scar. RESULTS New UMIs were detected in 37 subjects during follow-up. Plasma levels of hs-cTnI at 70 years of age, which were mainly within what is considered to be the normal range, were related to new UMIs at 75 years of age with an adjusted Odds Ratio (OR) of 1.7...