Circulation: Cardiovascular Imaging Editors’ Picks

Abstract

HomeCirculationVol. 127, No. 7Circulation: Cardiovascular Imaging Editors’ Picks Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCirculation: Cardiovascular Imaging Editors’ PicksMost Important Articles Published in 2012 The Editors The Editors Search for more papers by this author Originally published19 Feb 2013https://doi.org/10.1161/CIRCULATIONAHA.112.001342Circulation. 2013;127:e455–e460Utility of Cardiovascular Magnetic Resonance in Identifying Substrate for Malignant Ventricular ArrhythmiasSummary:Patients presenting with malignant ventricular arrhythmias outside of the setting of acute coronary syndrome pose a diagnostic and therapeutic challenge to the practicing clinician. One of the primary aims of cardiac imaging in this setting is the identification of underlying myocardial disease to offer plausible explanations for arrhythmia occurrence. However, the ability of diagnostic imaging to identify myocardial substrate for arrhythmia, the spectrum of such substrate that may be identified, and the incremental impact of these findings on diagnosis category are unknown. This study evaluated the diagnostic findings of routinely performed imaging other than cardiac magnetic resonance (CMR) versus comprehensive CMR to evaluate their respective diagnostic yield and impact on clinical diagnosis category in patients presenting with resuscitated sudden cardiac death (SCD) or sustained monomorphic ventricular tachycardia. In this population, a 50% increase in diagnostic yield of relevant myocardial disease was appreciated using CMR versus non-CMR imaging. This incremental yield translated into a new alternate diagnosis category being assigned in half of patients. For patients experiencing resuscitated SCD, approximately one third, by CMR, had unsuspected acute myocardial injury, offering identification of acute precipitants for otherwise unexplained cardiac arrest. In these patients, such findings may have important implications for therapeutic decision making and warrant further investigation. Overall, this study identifies that early CMR may be an efficient and high-yield diagnostic approach for the evaluation of patients presenting with malignant ventricular arrhythmias.Conclusion:CMR-based imaging provides a robust diagnostic yield in patients presenting with resuscitated SCD or sustained monomorphic ventricular tachycardia and incrementally identifies clinically unsuspected acute myocardial injury. When compared with non–CMRbased imaging, a new or alternate myocardial disease process may be identified in half of these patients.1Impact of Mitral Regurgitation on Reverse Remodeling and Outcome in Patients Undergoing Cardiac Resynchronization TherapySummary:We assessed the interplay of mitral regurgitation (MR) and cardiac resynchronization therapy (CRT) in 266 consecutive patients by looking at temporal changes in MR severity and left ventricular end-systolic volume index (LVESVi) during a follow-up that extended over several years. CRT led to an immediate and sustained decrease in MR (P0.0001), with no significant change during late follow-up, whereas ESVi increased slowly over the first several months, to become stable during late follow-up. The amount of MR decrease correlated with a greater decrease in LVESVi late, but not early, after CRT. Patients with severe MR pre-CRT experienced a larger LVESVi decrease. Although baseline MR severity was not associated with adverse events (defined as all-cause mortality, heart transplantation, or implantation of an LV assist device), larger MR decreases and less residual MR after the initial 6 months of CRT were predictive of better outcome in a multivariable model. In summary, early reversal of functional MR was associated with reverse cardiac remodeling and improved outcomes. Patients with moderately severe to severe MR before CRT experienced relatively more reverse remodeling than patients with lesser degrees of MR.Conclusion:Early reversal of functional MR was associated with reverse cardiac remodeling and improved outcomes. Patients with moderately severe to severe MR before CRT experienced relatively more reverse remodeling than patients with lesser degrees of MR.2Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Normal Ejection Fraction Is Associated With Severe Left Ventricular Dysfunction as Assessed by Speckle-Tracking Echocardiography: A Multicenter StudySummary:In a multicenter study concerning low-flow low-gradient aortic stenosis (LFLG AS) despite normal ejection fraction, the role of speckle tracking echocardiography in detecting subtle left ventricular dysfunction is reported. In addition to elevated afterload, the severe longitudinal dysfunction documented by 2D strain in these patients gives a new explanation to the concept of LFLG AS. The main findings of our study are 2-fold. First, among patients with severe AS, low gradient, and normal LV ejection fraction, 2 different patterns can be observed, with different hemodynamic characteristics and aortic severity. LFLG AS is observed in 9% of patients and is associated with high global afterload and reduced longitudinal systolic function. Patients with NFLG AS are more frequent and present with less severe AS, normal afterload, and less severe longitudinal dysfunction. Second, in clinical practice, 2 parameters are of major importance in the evaluation of patients with low-gradient severe aortic stenosis despite normal ejection fraction. Valvulo-arterial impedance allows an evaluation of LV afterload. It is significantly elevated in LFLG AS, and has been shown to be an independent prognostic factor. LV longitudinal dysfunction can be observed by 2D strain and is more severe in patients with LFLG AS as compared with other groups. The combined evaluation of global afterload (by valvulo-arterial impedance measurement) and of longitudinal systolic function (by 2D strain measurements) provides an optimal assessment of patients with low-gradient severe AS despite normal LV ejection fraction. This evaluation may help in separating patients with low-gradient AS into 2 groups of different severity.Conclusion:LFLG AS is observed in 9% of patients with severe AS and normal ejection fraction and is associated with high global afterload and reduced longitudinal systolic function. Patients with normal-flow low-gradient AS are more frequent and present with less severe AS, normal afterload, and less severe longitudinal dysfunction. Severe left ventricular longitudinal dysfunction is a new explanation to the concept of LFLG AS.3Nonculprit Plaques in Patients With Acute Coronary Syndromes Have More Vulnerable Features Compared With Those With Non–Acute Coronary Syndromes: A 3-Vessel Optical Coherence Tomography StudySummary:Patients with acute coronary syndrome (ACS) have a higher rate of recurrent ischemic events. Although it has been speculated that nonculprit plaques in ACS patients would have higher levels of plaque vulnerability, this concept has not been proven due to the lack of diagnostic modality. In the current study, an attempt was made to prove this hypothesis in vivo, using a high-resolution intravascular imaging modality: optical coherence tomography. Indeed, nonculprit lesions in the ACS subjects, as compared with non-ACS, have features consistent with plaque vulnerability: larger lipid volume, thinner fibrous cap, and a higher prevalence of thin-cap fibroatheroma, thrombus, macrophage, and superficial microvessels. This study supports the concept that ACS is a pan-vascular process with a higher prevalence of vulnerable plaques in nonculprit sites, which explains the higher recurrent ischemic events. Therefore, a more aggressive plaque stabilizing treatment such as cholesterol lowering and/or anti-inflammatory therapy may have additional value in ACS patients.Conclusion:Nonculprit lesions in patients with ACS have more vulnerable plaque characteristics compared with those with non-ACS. Neovascularization was more frequently located close to the lumen in patients with ACS.4Prevalence and Clinical Profile of Myocardial Crypts in Hypertrophic CardiomyopathySummary:We used cardiovascular MR to define the prevalence as well as clinical course and diagnostic significance of left ventricular myocardial crypts (ie, narrow and deep blood-filled invaginations contiguous with the left ventricular cavity, extending ≥50% of wall thickness) across the broad hypertrophic cardiomyopathy spectrum. Crypts were identified in 61% of asymptomatic genotype-positive/phenotype hypertrophic cardiomyopathy family members compared with only 4% of patients with hypertrophic cardiomyopathy with left ventricular hypertrophy (P<0.001). These observations expand the appreciation of diverse hypertrophic cardiomyopathy expression, particularly with respect to genotype-positive/phenotype-negative patients, and are a potential novel cardiovascular MR imaging marker for genotype-positive status in the absence of left ventricular hypertrophy, constituting an impetus to perform genetic testing to achieve definitive diagnosis. These data support an earlier role for cardiovascular MR in the assessment of hypertrophic cardiomyopathy family members.Conclusion:LV myocardial crypts represent a distinctive morphological expression of HCM, occurring with different frequency in HCM patients with or without LV hypertrophy. Crypts are a novel cardiovascular MR imaging marker, which may identify individual HCM family members who should also be considered for diagnostic genetic testing. These data support an expanded role for cardiovascular MR in early evaluation of HCM families.5Prediction of Arrhythmic Events in Ischemic and Dilated Cardiomyopathy Patients Referred for Implantable Cardiac Defibrillator: Evaluation of Multiple Scar Quantification Measures for Late Gadolinium Enhancement MRISummary:Scar signal quantification on late gadolinium enhancement cardiac magnetic resonance has been proposed to have use for the prediction of arrhythmic events in patients with ischemic cardiomyopathy eligible for implantable cardiac defibrillators (ICD). For this noninvasive tool to have widespread clinical value it would ideally be applicable to ischemic and nonischemic referral populations, predict highly relevant clinical outcomes (such as appropriate ICD therapy, resuscitated cardiac arrest, and sudden cardiac death), and demonstrate associations independent of other validated risk markers, such as ejection fraction. In the current study of 124 consecutively referred patients, we demonstrate that total scar burden by signal quantification is a reproducible imaging biomarker that appears to meet these desired criteria. While being sensitive to distinct thresholds for ischemic and nonischemic subcohorts, the quantification of total scar burden identifies patients at an elevated risk of future arrhythmic events. These findings support a need for the expanded investigation of this imaging modality to identify patients most likely to benefit from ICD implantation.Conclusion:Myocardial scar quantification by LGE-CMR predicts arrhythmic events in patients being evaluated for ICD eligibility irrespective of cardiomyopathy etiology.6Combined Cardiac MRI and C-Reactive Protein Levels Identify a Cohort at Low Risk for Defibrillator Firings and DeathSummary:The prevention of sudden cardiac death remains an imprecise science. Current clinical practice for selecting patients for primary prevention implantable cardioverter-defibrillators (ICDs) predominantly relies on demonstrating reduced left ventricular ejection fraction. However, this criterion lacks sensitivity and specificity. Although 80 000 Americans annually receive devices based on low left ventricular ejection fraction, only a minority (5% per year) will have appropriate ICD therapy, and a significantly larger number of patients will be subjected to the adverse effects of procedural complications, inappropriate discharges, infections, and device malfunctions. Prior studies have supported the role of the myocardial substrate in ventricular arrhythmogenesis. In the current study, we examined whether a combined index of myocardial tissue heterogeneity (gray zone) assessed by cardiac magnetic resonance could differentiate between low- and high-risk patients independently or in combination with serum biomarkers, such as high-sensitivity C-reactive protein. We prospectively enrolled 235 patients with ischemic and nonischemic cardiomyopathy. Patients who had the lowest levels of both gray zone and high-sensitivity C-reactive protein had the lowest risk of appropriate ICD discharges and cardiac death, with an annual incidence of 0.7% per year, which is below reported ICD-complication rates. These results are unique in identifying a low-risk cohort using combined risk indices that may reflect the underlying substrate and a proinflammatory environment that adversely modifies the myocardial substrate. Future prospective studies will be needed to determine whether such a strategy can be used to safely and cost-effectively reduce unnecessary ICD implantations.Conclusion:In a cohort of primary prevention ICD candidates, combining a myocardial heterogeneity index with an inflammatory biomarker identified a subgroup with a very low risk for adverse cardiac events, including ventricular arrhythmias. This novel approach warrants further investigation to confirm its value as a clinical risk stratification tool.7The Cycling of Acetyl-Coenzyme A Through Acetylcarnitine Buffers Cardiac Substrate Supply: A Hyperpolarized 13C Magnetic Resonance StudySummary:Increasingly, changes in metabolic substrate use and depleted myocardial energetics are considered to be causes, rather than consequences, of heart failure. Recent experimental studies have demonstrated that monitoring hyperpolarized 13C-labeled tracers with magnetic resonance spectroscopy offers a new, noninvasive method to investigate cardiac metabolism, and that the technology may be useful to determine diagnosis and prognosis and to optimize management of patients with heart disease. In the present study, we used the metabolic tracer hyperpolarized [2-13C]pyruvate with magnetic resonance spectroscopy to show that in healthy hearts, acetyl-coenzyme A formed from pyruvate rapidly cycles through the mitochondrial acetylcarnitine pool. Further, we demonstrated that the acetylcarnitine pool functions in vivo to continually fine-tune mitochondrial acetyl-coenzyme A levels, providing an overflow pool to prevent potentially deleterious acetyl-coenzyme A accumulation and a source of energetic substrate in response to rapidly increased cardiac workload. Many physiological and pathological conditions, including aging, hypertrophy, and heart failure, are characterized by depleted myocardial carnitine stores and energy depletion. Noninvasive assessment of the acetylcarnitine pool and other metabolic processes using hyperpolarized 13C magnetic resonance spectroscopy may advance our understanding of the importance of carnitine in heart failure, related abnormalities in heart failure, and targeted metabolic treatments.Conclusion:Hyperpolarized 13C magnetic resonance spectroscopy has revealed that acetylcarnitine provides a route of disposal for excess acetyl-CoA and a means to replenish acetyl-CoA when cardiac workload is increased. Cycling of acetyl-CoA through acetylcarnitine appears key to matching instantaneous acetyl-CoA supply with metabolic demand, thereby helping to balance myocardial substrate supply and contractile function.8A New Method for Cardiac Computed Tomography Regional Function Assessment: Stretch Quantifier for Endocardial Engraved Zones (SQUEEZ)Summary:Determination of left ventricular regional function is important in the diagnosis and management of cardiomyopathy. We describe a novel, CT-based method, SQUEEZ (Stretch Quantifier for Endocardial Engraved Zones), that provides highly quantitative measures of regional myocardial function and can distinguish between infarcted and normally contracting myocardial regions with minimal user interaction and high resolution. This approach may have particular clinical value in assessing patients with dyssynchronous heart failure to better identify their candidacy for cardiac resynchronization therapy and may help to guide cardiac resynchronization therapy lead placement to the most appropriate myocardial location. Additionally, SQUEEZ may help to assess myocardial dysfunction in patients with myocardial ischemia, especially when used in tandem with CT coronary atherosclerosis and emerging CT regional blood flow assessment techniques.Conclusion:We present a new quantitative method for measuring regional cardiac function from high-resolution volumetric CT images, which can be acquired during angiography and myocardial perfusion scans. Quantified measures of regional cardiac mechanics in normal and abnormally contracting regions in infarcted hearts were shown to correspond well with noninfarcted and infarcted regions as detected by delayed enhancement cardiovascular magnetic resonance images.9Morphological and Functional Adaptation of the Maternal Heart During PregnancySummary:Pregnancy represents a unique model of morphological, hemodynamic, and functional adaptation of the heart in a physiological situation of transient preload and afterload changes. The characterization and understanding of maternal cardiac function during normal pregnancy is of clinical importance for the recognition of cardiac pathology because heart disease is the leading cause of nonobstetric mortality during pregnancy. The present study aimed to assess the effects of normal pregnancy on left ventricular mechanics using standard and novel morphological and functional echocardiographic parameters while considering left ventricular load and shape. The data show that local deformation parameters are more sensitive to subtle myocardial changes than classical parameters and, therefore, may be used as possible screening tools for the early detection of pregnancy-associated disorders such as peripartum cardiomyopathy and preeclampsia. Because even those parameters reflect myocardial function only modulated by ventricular geometry, shape changes of the ventricle during pregnancy must be considered, or normal values need to be adjusted to the gestational age. Further studies are needed to assess the value of the technique in different pathologies.Conclusion:Pregnancy is a physiological process associated with increased cardiac performance and progressive LV remodeling. These changes are not directly reflected by parameters traditionally considered to describe systolic function, such as ejection fraction and longitudinal deformation. While ejection fraction was insensitive to the functional changes, the transient decrease in longitudinal deformation becomes only plausible when considering the changes in LV geometry.10Prognostic Implication of Appropriateness Criteria for Pharmacological Stress Echocardiography Performed in an Outpatient ClinicSummary:Appropriate use of imaging is the new imperative of contemporary medicine. In the words of the American College of Cardiology Foundation committee, “appropriate echocardiograms are those that are likely to contribute to improving patients’ clinical outcomes, and importantly, inappropriate use of echocardiography may be potentially harmful to patients and generate unwarranted costs to the healthcare system.” Hence, these criteria stem from a real practical need to reduce costs and avoid abuse and misuse of noninvasive imaging technologies. Even though appropriateness criteria are highly cited and referred to, the real impact of these documents is yet to come. These results attempt to shed light on the prognostic impact of the criteria and tell us that appropriate tests identify patients at higher risk of events during follow-up, whereas inappropriate studies, performed on low-risk patients, identify a subset at very low risk.Conclusion:Inappropriate indication for pharmacological stress echo is common, being documented in about 1 of 4 patients evaluated in an ambulatory setting, and is associated with lower rate of positive results and better survival as compared with appropriate and uncertain indication.11High-Resolution Versus Standard-Resolution Cardiovascular MR Myocardial Perfusion Imaging for the Detection of Coronary Artery DiseaseSummary:Coronary artery disease is the leading cause of death worldwide and accurate methods of detection are therefore important. Furthermore, the detection of ischemia in patients with known coronary artery disease is increasingly used to guide revascularization decisions, particularly in complex cases. Myocardial perfusion cardiovascular MR (CMR) has emerged as a highly accurate modality to detect ischemia, and the recent CE-MARC study demonstrated a higher diagnostic accuracy compared with single photon emission CT. Myocardial perfusion CMR offers significantly greater spatial resolution than single photon emission CT without any ionizing radiation exposure. In this study of 100 patients, we used a new technique to increase the spatial resolution of myocardial perfusion CMR even further (<2 mm in-plane). The results showed that overall diagnostic accuracy as measured by the area under the receiver operator curve was better with the high spatial resolution technique. In addition, high-resolution myocardial perfusion CMR allowed better detection of subendocardial ischemia and better correlation with scar on late gadolinium-enhanced CMR. We propose that high-resolution myocardial perfusion CMR shows promise for the screening of patients with suspected coronary artery disease and as a guide to management in cases of established coronary artery disease, in particular as part of a comprehensive CMR assessment of myocardial function, viability, and perfusion.Conclusion:High-resolution perfusion-CMR has greater overall diagnostic accuracy than standard-resolution acquisition for the detection of coronary artery disease in both single- and multivessel disease and detects more subendocardial ischemia.12Effects of Hemodynamics on Global and Regional Lung Perfusion: A Quantitative Lung Perfusion Study by MRISummary:Using lung perfusion quantification by MRI, we demonstrated the complex association of lung perfusion with cardiac output and hemodynamics. Although absolute global and regional lung perfusion were determined mainly by cardiac output, regional perfusion distribution was affected by hemodynamic abnormalities, predominantly elevated left ventricular end-diastolic pressure and resultant increases in mean pulmonary artery pressure. Among those with significantly elevated left ventricular end-diastolic pressure, there was near equalization of lung perfusion from anterior to posterior lung fields in the supine position, abolishing the normal gravitational lung perfusion gradient. Multivariate regression analysis suggested that mean pulmonary artery pressure was the most important determinant of altered perfusion distribution among all the hemodynamic indices, underscoring the importance of the pulmonary arterial response to left ventricular enddiastolic pressure and not simply left ventricular end-diastolic pressure alone in the pathophysiology of left heart failure. Our findings underscore the complexity of heart-lung interactions in determining pulmonary hemodynamics in left heart failure.Conclusion:Increased left ventricular filling pressure and the resultant increase in pulmonary arterial pressure are associated with disruption of the normal gravitational lung perfusion gradient. Our findings underscore the complexity of heart-lung interaction in determining pulmonary hemodynamics in left heart failure.13Diagnostic Accuracy of Cardiac Positron Emission Tomography Versus Single Photon Emission Computed Tomography for Coronary Artery Disease: A Bivariate Meta-AnalysisSummary:Positron emission tomography (PET) and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are both established techniques for noninvasively diagnosing coronary artery disease. PET MPI has technical benefits in detecting sensitivity and spatial resolution compared with SPECT MPI and may also allow diagnostic imaging with lower radiation exposure. Clinical differences in diagnostic accuracy remain under investigation. A literature search of English-language studies yielded 117 diagnostic accuracy studies of MPI for detecting 50% angiographic coronary stenosis but only 5 direct comparisons of PET and SPECT. These were systematically reviewed and scored for methodological quality before meta-analysis using techniques designed for analyzing the relationship between sensitivity and specificity. Both PET and SPECT MPI were more commonly performed after pharmacological, as opposed to exercise, stress. Pooled sensitivity was higher for PET MPI at 92.6% compared with 88.3% for SPECT MPI. Pooled specificity was lower, without a clear difference between PET and SPECT MPI. Type of stress (exercise or pharmacological) and differences in radiotracer used did not seem to affect diagnostic accuracy. More research, especially in head-to-head comparisons, will be needed to identify patient groups most likely to benefit from PET MPI.Conclusion:In a meta-analysis of 11,862 patients, PET MPI demonstrated a higher sensitivity for coronary artery disease than SPECT MPI. No difference in specificity was detected in the pooled analysis of PET and SPECT MPI.14Prognostic Impact of Hyperglycemia in Nondiabetic and Diabetic Patients With ST-Elevation Myocardial Infarction: Insights From Contrast-Enhanced MRISummary:Previous studies have suggested that hyperglycemia on admission is a risk factor for increased mortality in patients with acute ST-elevation myocardial infarction (STEMI). However, data regarding the relationship between hyperglycemia and myocardial damage in STEMI are scarce. This largest cardiac magnetic resonance study to date evaluating the relationship of diabetes mellitus status and elevated glucose levels on admission on myocardial damage in STEMI patients reperfused by primary percutaneous coronary intervention has 2 essential findings: (1) STEMI patients with preexisting diabetes mellitus are at greater risk for major adverse cardiovascular events despite having similar infarct sizes and extent of reperfusion injury than patients without known diabetes mellitus. (2) Elevated glucose levels on admission are associated with greater myocardial damage (larger infarcts, more pronounced reperfusion injury, left ventricular dysfunction) and an increased risk of clinical events at long-term follow-up. However, hyperglycemia was a stronger indicator of myocardial injury in STEMI patients without previously recognized diabetes mellitus than in those with established diabetes mellitus. Thus, our study confirms and expands previous findings by demonstrating that the amount of myocardial injury does not explain the substantially higher mortality rates in diabetic patients with STEMI. Moreover, we could demonstrate that the relationship between hyperglycemia and myocardial damage is different in STEMI patients with and without known diabetes mellitus.Conclusion:The higher mortality rate in diabetic versus nondiabetic STEMI patients is not explained by more pronounced myocardial damage. Hyperglycemia on admission is associated with greater myocardial injury and an increased risk of major adverse cardiovascular events at long-term follow-up. However, hyperglycemia has a stronger relationship to myocardial injury in nondiabetic compared with diabetic patients.15Characterizing Myocardial Edema and Hemorrhage Using Quantitative T2 and T2* Mapping at Multiple Time Intervals Post ST-Segment Elevation Myocardial InfarctionSummary:Cardiovascular MRI has gained clinical importance in the noninvasive assessment of myocardial injury parameters including myocardial edema, hemorrhage, microvascular obstruction, and infarct size post acute myocardial infarction. We prospectively characterized the evolution of these parameters post reperfused acute myocardial infarction at both early and late time points. We noted that edema is still present in infracted tissue at 3 weeks, whereas hemorrhage resolves faster. Noninfarcted segments can demonstrate edema in the acute phase as well, perhaps indicative of more severe myocardial injury. The presence of hemorrhage in the acute phase makes edema quantification challenging due to susceptibility effects. In addition, both hemorrhage and microvascular obstruction are associated with worse left ventricular remodeling. Gaining this knowledge about the temporal resolution of myocardial damage and its impact on remodeling processes using quantitative techniques is potentially important in grading severity, evaluating treatment strategies, and improving clinical outcomes.Conclusion:Quantification of myocardial edema and hemorrhage by T2 and T2* mapping is feasible post acute myocardial infarction and demonstrates that hemorrhage resolves faster than edema. Noninfarcted segments can also demonstrate edema in the acute phase possibly due to global hyperemia.16Myocardial Perfusion Reserve Assessed by T2-Prepared Steady-State Free Precession Blood Oxygen Level–Dependent MRI in Comparison to Fractional Flow ReserveSummary:T2-prepared steady-state free precession blood oxygen level–dependent cardiac MRI is based on different magnetic properties of oxyhemoglobin and deoxyhemoglobin. This results in a relative decrease of T2* and T2 relaxation time in ischemic and thus lower oxygenated myocardium. In our study, we demonstrate that this effect correlates to invasively measured fractional flow reserve in the respective coronary artery. Our described approach warrants consideration as an alternative to contrast–enhanced perfusion studies, especially in patients with severe renal failure in which the use of exogenous contrast agents should be avoided.Conclusion:CMR BOLD imaging reliably detects hemodynamic significant coronary artery disease and is, thus, an alternative to contrast–enhanced perfusion studies.17Assessment of Echocardiography and Biomarkers for the Extended Prediction of Cardiotoxicity in Patients Treated With Anthracyclines, Taxanes, and TrastuzumabSummary:Because cancer patients survive longer, the impact of cardiotoxicity associated with the use of cancer treatments on cardiac morbidity and mortality is increasing. Left ventricular ejection fraction is the recognized method to monitor the cardiotoxic effects of cancer treatments; however, it may not detect subtle myocardial injury. The present study investigated whether early alterations of myocardial strain and blood biomarkers could predict incident cardiotoxicity in a cohort of 81 patients with breast cancer during treatment with anthracyclines followed by taxanes and trastuzumab. Peak systolic longitudinal myocardial strain and ultrasensitive troponin I measured after completion of the anthracyclines were predictive of cardio-toxicity (defined by a decrease of left ventricular ejection fraction with or without symptoms of heart failure) occurring later during the treatment. In patients with breast cancer treated with anthracyclines, taxanes and trastuzumab, systolic longitudinal myocardial strain and ultrasensitive troponin I measured at the completion of anthracyclines therapy are useful in the prediction of subsequent cardiotoxicity and may help guide treatment to avoid cardiac side-effects.Conclusion:In patients with breast cancer treated with anthracyclines, taxanes, and trastuzumab, systolic longitudinal myocardial strain and ultrasensitive troponin I measured at the completion of anthracyclines therapy are useful in the prediction of subsequent cardiotoxicity and may help guide treatment to avoid cardiac side-effects.18FootnotesThe following articles are being highlighted as part of Circulation’s Topic Review series. This series summarizes the most important manuscripts, as selected by the editors, published in Circulation and the Circulation subspecialty journals. The studies included in this article represent Editors’ Picks for each Circulation: Cardiovascular Imaging issue published in 2012.Correspondence to The Editors, Circulation Editorial Office, 560 Harrison Ave, Suite 502, Boston, MA 02118. E-mail [email protected]