Basal Short Axis Research Articles

The Association of Epicardial Adipose Tissue Volume and Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: As Assessed by Cardiac MR.

Epicardial adipose tissue (EAT) is a metabolically active visceral fat linked to cardiovascular disease. Prior studies demonstrated the predictive value of EAT volume (EATV) in atrial fibrillation (AF) among hypertrophic obstructive cardiomyopathy patients. To investigate the association between EATV and AF in hypertrophic cardiomyopathy (HCM). Retrospective. Two hundred and twenty-four HCM patients (including 79 patients with AF and 145 patients without AF, 154 men) and 80 healthy controls (54 men). 3.0 T scanner; balanced steady-state free precession (SSFP) cine sequence, gradient echo. EAT thickness was assessed in the 4-chamber and basal short-axis planes. EAT volume was calculated by outlining the epicardial border and visceral pericardium layer on short-axis cine images. Shapiro-Wilk test, Student's t test or the Mann-Whitney U test, chi-square test or Fisher's exact test, Multivariate linear regression analyses, Multivariable binary logistic regression analysis. Intraclass correlation coefficient. Significance was determined at P < 0.05. EATV and EAT volume index (EATVI) were significantly greater in HCM patients with AF than those without AF (126.6 ± 25.9 mL vs. 90.5 ± 24.5 mL, and 73.0 ± 15.9 mL/m2 vs. 51.3 ± 13.4 mL/m2). EATVI was associated with AF in multivariable linear regression analysis among HCM patients (β = 0.62). Multivariable logistic regression analysis revealed that compared to other indicators, the area under curve (AUC) of EATVI was 0.86 (cut-off, 53.9 mL/m2, 95% CI, 0.80-0.89), provided a better performance, with the sensitivity of 96.2% and specificity of 58.6%. The combined model exhibited superior association with AF presence compared to the clinical model (AUC 0.96 vs. 0.76) and the imaging model (AUC 0.96 vs. 0.93). EATVI was associated with AF. EATVI was significantly correlated with incident AF, and provided a better performance in HCM patients compared to other indicators. 3 TECHNICAL EFFICACY: Stage 2.

Inter-scanner comparability of Z-scores for native myocardial T1 and T2 mapping

BackgroundCardiovascular Magnetic Resonance (CMR) native T1 and T2 mapping serve as robust, contrast-agent-free diagnostic tools, but hardware- and software-specific sources of variability limit the generalizability of data across CMR platforms, consequently limiting the interpretability of patient-specific parametric data. Z-scores are used to describe the relationship of observed values to the mean results as obtained in a sufficiently large normal sample. They have been successfully used to describe the severity of quantifiable abnormalities in medicine, specifically in children and adolescents. The objective of this study was to observe whether z-scores can improve the comparability of T1 and T2 mapping values across CMR scanners, field strengths, and sequences from different vendors in the same participant rather than different participants (as seen in previous studies). MethodsFifty-one healthy volunteers (26 men/25 women, mean age = 43 ± 13.51) underwent three CMR exams on three different scanners, using a Modified Look-Locker Inversion Recovery (MOLLI) 5-(3)− 3 sequence to quantify myocardial T1. For T2 mapping, a True Fast Imaging with steady-state free precession (TRUFI) sequence was used on a 3 T Skyra™ (Siemens), and a T2 Fast Spin Echo (FSE) sequence was used on 1.5 T Artist™ (GE) and 3.0 T Premier™ (GE) scanners. The averages of basal and mid-ventricular short axis slices were used to derive means and standard deviations of global mapping values. We used intra-class comparisons (ICC), repeated measures ANOVA, and paired Student’s t-tests for statistical analyses. ResultsThere was a significant improvement in intra-subject comparability of T1 (ICC of 0.11 (95% CI= −0.018, −0.332) vs 0.78 (95% CI= 0.650, 0.866)) and T2 (ICC of 0.35 (95% CI= −0.053, 0.652) vs 0.83 (95% CI= 0.726, 0.898)) when using z-scores across all three scanners. While the absolute global T1 and T2 values showed a statistically significant difference between scanners (p < 0.001), no such differences were identified using z-scores (T1z: p = 0.771; T2z: p = 0.985). Furthermore, when images were not corrected for motion, T1 z-scores showed significant inter-scanner variability (p < 0.001), resolved by motion correction. ConclusionEmploying z-scores for reporting myocardial T1 and T2 removes the variation of quantitative mapping results across different MRI systems and field strengths, improving the clinical utility of myocardial tissue characterization in patients with suspected myocardial disease.

The impact of surgical aortic valve replacement on myocardial deformation in patients with severe aortic stenosis: a comparison between echocardiography and CMR

Abstract Background Aortic valve replacement (AVR) in patients with severe aortic stenosis (AS) leads to reverse remodelling, with reduction in left ventricle (LV) mass and volumes. However, the effect of AVR on left atrial (LA) and LV myocardial deformation using speckle tracking echocardiography (STE) and feature tracking cardiac magnetic resonance (FT-CMR) has not been extensively compared in the same cohort. Methods Patients with severe AS scheduled for AVR were recruited. Same-day TTE and CMR scans were performed pre- and post-AVR using a standard protocol. Myocardial deformation was assessed using STE and FT-CMR by a blinded single observer. LA strain (LAS) corresponding to reservoir, conduit and booster pump function were assessed on 4- and 2-chamber and average values calculated. For the LV, the three long-axis views were utilised for global longitudinal strain (GLS) and peak early diastolic strain rate (PEDSR). Mid circumferential strain (Mid-CS) and PEDSR were calculated from the mid short-axis view. Global circumferential strain (GCS) and PEDSR were derived by averaging values from the basal, mid and apical short axis cine slices by FT-CMR only. Results We recruited 78 patients with severe AS, 66 of whom (mean age 67.0±9.4 years; 75.8% males) had matched pre- and post-AVR CMR scans. Median follow-up period was 6 months. LV assessment by TTE was limited by image quality (&amp;gt;20% unanalysable images). STE demonstrated a significant increase in reservoir and conduit LAS, GLS and longitudinal PEDSR post-AVR (Table 1&amp;2). FT-CMR demonstrated a significant increase in booster-pump LAS, GLS, GCS and longitudinal/ circumferential-PEDSR post-AVR. Conclusion In patients with severe AS, significant increase in LV GLS and longitudinal-PEDSR was seen using both FT-CMR and STE. GCS and circumferential-PEDSR were significantly increased using FT-CMR only, suggesting that CMR may be more sensitive to subtle changes in LV function at 6 months post-AVR. LAS assessment showed significant improvements post-AVR by both imaging modalities.Table 1Table 2

Indipendent predictors of akinetic segment recovery during dobutamine infusion assessed by cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: None. Background Myocardial viability assessment can guide myocardial revascularization in patients with coronary artery disease. Non-invasive imaging modalities are routinely used for detection of viable myocardium and the highest diagnostic performance is provided by Cardiac Magnetic Resonance (CMR): it combines high sensibility (95%) by delayed enhancement (DE) assessment and high specificity (91%) by evaluation of myocardial systolic thickening recovery at increasing dose of dobutamine (Db-systolic recovery). Purpose Identification of independent predictors for Db-systolic recovery of akinetic segments supplied by a chronic total occlusion (CTO) coronary artery. The second purpose was to develop a diagnostic tool as alternative to dobutamine stress imaging to provide an estimation of myocardial response to inotropic agents. Methods This single center prospective observational study enrolled 47 consecutive patients referred to CMR for evaluation of inducible ischemia and myocardial viability in the territory of one or more CTOs. All enrolled patients presented basal akinetic segments in the CTO territory. Cine-Steady State Free Precession (SSFP) sequences were acquired both in basal and at increasing dose of dobutamine to evaluate Db-systolic recovery. Stress perfusion imaging and DE were then acquired to detect inducible ischemia and necrotic areas. Post-processing CMR-Feature Tracking strain analysis provided both radial and circumferential strain on basal, mid and apical short axis planes. Results Table 1 lists clinical characteristics of the study population. A total of 189 akinetic segments supplied by a CTO were detected and divided into viable and non-viable groups according to their ability to recover or not at increasing dose of dobutamine, respectively. Parameters of each akinetic segment significantly (p value &amp;lt; 0.05) associated with viability at univariate analysis were included in the multivariable binary logistic regression to identify independent predictors of Db-systolic recovery (Table 2). These independent predictors have been then included in a logistic regression model as continuous variable except for Transmural Extent of DE which can be either 1 or 0 according to DE&amp;lt;75% or ≥75%, respectively: L= −5.459 + 0.033 * (Radial Peak Systolic Strain) + 0.067 * (Circumferential Endocardial Peak Systolic Strain) + 1.808 * (Transmural Extent of DE) + 0.358 * (Diastolic Wall Thickness). When L ≥ 0 the model predicts contractile recovery during dobutamine infusion with an accuracy of 83.1%. Conclusion This CMR prospective study identifies independent predictors of contractile recovery at increasing dose of dobutamine and provides a diagnostic tool which might substitute dobutamine assessment with a good accuracy, reducing acquisition time and adverse events in patients with CTOs. An external validation study is needed to assess the consistency of this model for clinical purposes.

Hepatic t1 mapping: a new easily obtained biomarker for heart failure patients undergoing cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hepatic venous pressure overload and subsequent liver damage are frequent in patients with Chronic Heart Failure (CHF) but are difficult to quantify except in the late stages of disease. Myocardial T1 mapping is now commonly performed in patients undergoing cardiac magnetic resonance (CMR), with short axis images usually intercepting the liver, therefore allowing the opportunistic measurement of hepatic T1 values. Purpose The aim of this study was to quantify hepatic T1 values in HF patients undergoing CMR, and to assess its clinical and prognostic significance as a biomarker in this setting. Methods Consecutive patients with CHF (LVEF ≤ 50%) who underwent CMR at a single centre since Jan2019 were retrospectively identified. Those with known chronic liver disease, cardiac amyloidosis or suspected alcoholic cardiomyopathy were excluded. Native myocardial T1 mapping [MOLLI 5(3)3 sequence] basal short axis images were used to measure hepatic T1, with the region of interest drawn in the liver, avoiding organ vessels. A control group of subjects without known cardiovascular disease (n=57) was used to define the limits of normality for hepatic T1 values. The clinical significance of hepatic T1 values was assessed by its relationship with markers of right-sided CHF, and its prognostic value by the association with cardiovascular mortality. Results A total of 267 patients (mean age 62±15 years, 69% men, 38% with ischemic cardiomyopathy) were included. Median LVEF was 35% (IQR 26 – 44%) and median RVEF was 51% (IQR 40 – 59%). Overall, 46 patients (17%) had hepatic T1 values above 684 ms (the upper limit of normal for controls). Patients with elevated hepatic T1 had significantly higher RV volumes and lower RVEF (all p values &amp;lt;0.03). Hepatic T1 values were significantly higher in patients with RVEF&amp;lt;45% and in those with moderate or severe tricuspid regurgitation (Figure 1), and were also inversely correlated with RVEF (Spearman R −0.20, p&amp;lt;0.001). During a median follow-up period of 17 months (IQR 11–24), there were 11 cardiovascular deaths. Elevated hepatic T1 was associated with an increased risk of this endpoint (HR 3.04, 95%CI 1.02 – 9.11, p = 0.047). Conclusions Hepatic T1 values can be easily measured in standard myocardial T1 maps, are associated with markers of right-sided heart failure, and have prognostic value in patients with HF. Further studies are warranted to assess the potential clinical usefulness of this new biomarker.

S-52-3: ROLE OF NOVEL ECHOCARDIOGRAPHIC METHODS TO DETECT EARLY MYOCARDIAL DYSFUNCTION IN WOMEN WITH PREECLAMPSIA

Normal pregnancy is associated with reversible changes in both systolic and diastolic mechanics, consistent with an increase in preload and decrease in afterload and systemic vascular resistance. The aim of the study is to evaluate left ventricular cardiac mechanics via speckle tracking echocardiography in a population of pregnant women with per partum cardiomyopathy and preeclampsia(PE) after invitro fertilization (IVF) during different stages of pregnancy. The study population included 525 pregnant women with PE, after IVF, 100 of them with multiple pregnancy (46.5 ± 3 years) and 30 healthy nonpregnant women (33 ± 4years).Apical and basal short axis and apical view for three, two and four chamber for 2D images were acquired (65 ± 7 frames/s) during the first, second and third trimester of the pregnancy, as well as up to two months post partum. The curves of longitudinal(GLS), circumferential(GCS), radial strain(GRS) and LVT /LVUR were extracted using a commercial software. Results: Peak LVT and LVUR increased significantly in the 3rd trimester in both pregnancy groups (13.48 ± 2.90°,13.12 ± 3.30?,16.83 ± 3.61?,P &lt; 0.001; and -111.52 ± 23.54°/sec,-107.40 ± 26.58?/sec,-144.30 ± 45.14?/sec, P &lt; 0.001; in the 1st, 2nd, and 3rd trimester, respectively.The pregnants with twins have the highest value for LVT and LVUR compare with other pregnants (p &lt; 0.01), but in the last trimester, the time to peak LVUR is prolonged. An independent correlation was found between the change in LVT and LV end-systolic volume in 1st and 3rd trimester (r = 0,56). Peak LVUR at the 3rd trimester correlated significantly with LV end-diastolic volume. Multiple regression analysis indicates that only systolic blood pressure (r = 0.394, P = 0.005) was an independent predictor for increased LV torsion. Arterial hypertension (AH) and prevalence of preeclampsia (PE) are more often in IVF group. Longitudinal strain decreased significantly (p &lt; 0.001) during 3th trimester in women with AH and PE. Global longitudinal strain measures of the LV were non-significantly different between the different groups in first and second trimester (GLS-20.6 ± 3,14 vs.-19,29 ± 2,17).There are not found significant differences for GCS and GRS during pregnancy. Conclusions: During pregnancy LV twist and peak untwisting rate increase in the 3rd trimester and correlate with end-systolic and end-diastolic volume, respectively. Blood pressure and condition of multiple pregnancy are independently associated with increased torsion during pregnancy and may predict the new onset heart failure and perinatal cardiomyopathy. Global longitudinal strain is the main predictor of new onset peripartum cardiomyopathy

Abstract 11000: Deep Learning Prediction of New-Onset Atrial Fibrillation Using Echocardiography Videos

Introduction: Patients at high risk of undiagnosed Atrial Fibrillation (AF) can be identified from 12-lead ECG and routed to increased monitoring via wearable devices such as a watch or an ECG patch. A similar prediction task may be feasible employing echocardiography, increasing the likelihood of detecting patients at high risk for AF. Hypothesis: We hypothesized that by leveraging a large echocardiography database, a model can be trained to accurately predict future AF onset in patients undergoing routine echocardiography. Methods: We collected data on patients with an echo at Geisinger (769,854 studies from 337,388 patients) and randomly grouped patients into training (80%) or testing (20%) sets. In the training cohort, studies were considered positive if they were obtained from patients with prior or new (&lt;1 year) AF diagnosis. Alternatively, negative studies were those obtained from AF-free patients (&gt;1 year). For testing, we selected one random echo per patient and restricted the positives to patients without prior AF diagnosis or new AF within 7 days of the echo. This was to avoid predicting positive AF at the time of echo. We tested the model on 38,808 valid studies where 5% developed AF within a year. We trained six convolutional neural networks, one per view (apical two, four and five chambers, basal and mid short-axis, and parasternal long-axis), and combined their outputs to train an XGboost model. Results: Among the six views, the apical four chamber yielded the best performance with an area under the ROC curve (AUROC) of 76%, followed by the apical two chamber with 65%, the apical five chamber with 58%, the parasternal long-axis with 57%, the basal short-axis with 56%, and the mid short-axis with 50%. A model combining all six planes yielded a 78% AUROC. Conclusions: CNN models trained on echocardiography videos can predict new-onset AF with moderate performance. We also found that views that captured the left atrium had better performance compared to those that did not.

Definition of left ventricular dilation in heart failure using cardiovascular magnetic resonance: prognostic implications of end-diastolic diameter and volume assessment

Abstract Background Patients with heart failure (HF) and reduced or mildly reduced ejection fraction (HFrEF/HFmrEF) display variable grades of left ventricular (LV) dilation. LV end-diastolic diameter (LVEDD) and volume (LVEDV) may not be concomitantly increased. The respective prognostic implications of LV dilation have not been explored. Purpose To assess the prognostic implications of LVEDD and LVEDV index (LVEDVi) in HFrEF/HFmrEF. Methods Data from consecutive HF outpatients undergoing cardiovascular magnetic resonance (CMR) and with LV ejection fraction &amp;lt;50% were analyzed. LVEDD was measured in a basal short axis slice. Established age- and gender-specific cut-offs for LVEDVi and a cut-off of 58 mm for LVEDD were used to define LV dilation. Patients were followed for the occurrence of the combined endpoint of cardiovascular death or HF hospitalization. Results A total of 564 patients (79% men, median age 65 years [56–73], ischaemic aetiology in 32%) were included. HFrEF was present in 85% of patients, and HFmrEF in 15%. Median values for LVEDD and LVEDVi were 63 mm (58–69) and 124 mL/m2 (104–149) respectively. LVEDD was significantly correlated with LVEDVi (r=0.804, p&amp;lt;0.001). Sixty-nine percent of patients had concomitant dilation of LV based on LVEDD and LVEDVi. In contrast, 18% of patients did not have concordant definition of LV dilation based on LVEDVi and LVEDD, including 14% with small LVEDD and large LVEDVi. LV dilation based on LVEDVi was associated with a shorter survival free from CV death or HF hospitalization (log-rank 4.6, p=0.032), while LVEDD &amp;gt;58 mm was not (p=0.278). There was a trend toward an independent association between LV dilation based on LVEDVi and outcome adjusting for HFrEF/HFmrEF status and ischaemic aetiology (hazard ratio 2.10, 95% confidence interval 1.00–4.41, p=0.050). An independent association was not found for LV dilation based on LVEDD. An LVEDD &amp;gt;66 mm was associated with increased risk of CV death or HF hospitalization on spline curve analysis (Figure 11). All patients with an LVEDD &amp;gt;66 mm had also LV dilation based on LVEDVi. Conclusions In patients with HFrEF and HFmrEF, LV dilation based on LVEDVi does not always coincide with a dilated LVEDD. The cut-off value of LVEDD associated with an excess of the combined endpoint is much larger than the value used in clinical practice. However, in patients with dilated LV based on LVEDVi, LVEDD does not add to the risk stratification. Funding Acknowledgement Type of funding sources: None.

Saturation-pulse prepared heart-rate independent inversion-recovery (SAPPHIRE) biventricular T1 mapping: inter-field strength, head-to-head comparison of diastolic, systolic and dark-blood measurements

BackgroundTo assess the feasibility of biventricular SAPPHIRE T1 mapping in vivo across field strengths using diastolic, systolic and dark-blood (DB) approaches.Methods10 healthy volunteers underwent same-day non-contrast cardiovascular magnetic resonance at 1.5 Tesla (T) and 3 T. Left and right ventricular (LV, RV) T1 mapping was performed in the basal, mid and apical short axis using 4-variants of SAPPHIRE: diastolic, systolic, 0th and 2nd order motion-sensitized DB and conventional modified Look-Locker inversion recovery (MOLLI).ResultsLV global myocardial T1 times (1.5 T then 3 T results) were significantly longer by diastolic SAPPHIRE (1283 ± 11|1600 ± 17 ms) than any of the other SAPPHIRE variants: systolic (1239 ± 9|1595 ± 13 ms), 0th order DB (1241 ± 10|1596 ± 12) and 2nd order DB (1251 ± 11|1560 ± 20 ms, all p < 0.05). In the mid septum MOLLI and diastolic SAPPHIRE exhibited significant T1 signal contamination (longer T1) at the blood-myocardial interface not seen with the other 3 SAPPHIRE variants (all p < 0.025). Additionally, systolic, 0th order and 2nd order DB SAPPHIRE showed narrower dispersion of myocardial T1 times across the mid septum when compared to diastolic SAPPHIRE (interquartile ranges respectively: 25 ms, 71 ms, 73 ms vs 143 ms, all p < 0.05). RV T1 mapping was achievable using systolic, 0th and 2nd order DB SAPPHIRE but not with MOLLI or diastolic SAPPHIRE. All 4 SAPPHIRE variants showed excellent re-read reproducibility (intraclass correlation coefficients 0.953 to 0.996).ConclusionThese small-scale preliminary healthy volunteer data suggest that DB SAPPHIRE has the potential to reduce partial volume effects at the blood-myocardial interface, and that systolic SAPPHIRE could be a feasible solution for right ventricular T1 mapping. Further work is needed to understand the robustness of these sequences and their potential clinical utility.

Loss of apical suction assessed by noninvasive pressure differences and twist in acute heart failure: a novel method using vector flow mapping

Abstract Background Early diastolic intraventricular pressure difference (IVPD) reflects left ventricular (LV) apical suction, and IVPD is closely related to cardiac function, especially LV twist. Vector Flow Mapping (VFM) allows visualization of regional pressure distribution and noninvasive quantification of IVPD. The purpose of the present study was to investigate if and how IVPDs are related to LV twist in a model of acute heart failure (HF). Methods In 15 open-chest dogs, HF was induced by intracoronary injection of microspheres. The HF model was classified into two groups based on the LV end-diastolic pressure (LVEDP) (group1: LVEDP&amp;lt;18 mmHg (n=10), group2: LVEDP≥18 mmHg (n=8)). Color Doppler images from apical long-axis views were acquired at baseline and during HF. From these images, pressure differences (ΔP) were calculated along the LV inflow tract throughout the cardiac cycle. For the purpose of this study, the differences between apex and base during isovolumic relaxation time (ΔPIRT) and rapid early inflow period (ΔPE) were used for analyses. Furthermore, apical and basal short axis high frame rate 2D images were acquired, and peak rotation and peak twist were analyzed. Results LVEDP was 7±9, 14±2, 21±3 mmHg for baseline, group1 HF, and group2 HF, respectively. Pressure differences (both ΔPIRT and ΔPE) were visibly changed by the increase of LVEDP (Figure), and the magnitude of ΔPIRT, ΔPE and peak twist decreased significantly with the severity of heart failure. There were significant relationships between pressure differences (ΔPIRT and ΔPE) and dP/dtmin, tau, EF and peak twist (Table). In multivariate analyses, tau and peak twist were independent predictors for ΔPIRT and peak twist was independent predictor for ΔPE. Conclusion VFM analysis is feasible to noninvasively assess the IVPDs in acute heart failure. The IVPDs are closely related to the twisting motion of the LV, and reflect loss of apical suction during severe HF. Funding Acknowledgement Type of funding sources: None. VFM images of pressure differencesCorrelations of pressure differences

Prevalence of pericardial late gadolinium enhancement in patients after cardiac surgery: clinical and histological correlation

Abstract Funding Acknowledgements Type of funding sources: None. Background Opening of the pericardial sack during cardiac surgery induce usually, a mild inflammatory reaction. Late gadolinium enhancement of the pericardium (pLGE) still has been observed on cardiovascular magnetic resonance (CMR) in patients even long-time after cardiac surgery suggesting ongoing pericardial inflammation. Clinical relevance and histological correlation are unknown. We present a study evaluating the prevalence of pLGE and correlating it to clinical and histological findings. Materials and Methods 185 patients after cardiac surgery underwent CMR on a 1.5 or 3.0 T system. Presence (LGE+) or absence (LGE-) of pLGE was rated by 2 independent operators blinded to clinical characteristics. In case of discordance a third observer served as referee. Information on clinical symptoms were obtained at the time of CMR or from medical records. A pericardial biopsy was performed in 4 patients who underwent a second cardiac surgical intervention after CMR. Results Mean time between CMR and cardiac surgery was 158 ± 110 months. Pericardial LGE was observed in 83 patients (38%), two independent observers agreed in 73 (89%). The presence of LGE was not significant correlated to the type (p = 0.812) or duration of surgery (p = 0.734), nor the use of intrapericardial foreign material (p = 0.534). Two biopsies in LGE + patients showed mild inflammation and calcification, one biopsy in a LGE + patient showed the presence of fibrosis without inflammation while one biopsy in a LGE – patient was negative for inflammation. None of patients presented clinical signs for an active pericarditis. Discussion Presence of pericardial LGE is frequent in patient after cardiac surgery, however without clinical features of pericarditis. The CMR findings appear to be histologically correlated to the presence of fibrosis or mild chronic inflammation which remains to be confirmed in a larger patient population. Figure 1: Basal ventricular short axis view in LGE sequences showing the presence of LGE of the pericardium (Panel A, yellow arrows) compatible with mild inflammation present in histological findings, shown by the presence of T lymphocytes CD3+ (Panel B) and the presence of fibrin (Panel C) : (hematoxylin and eosin) and (Panel D) : (FAOG). Mid-ventricular short axis view in LGE sequences showing the presence of LGE of the pericardium (Panel E, yellow arrows), which is compatible with histological findings, showing the presence of granulomatous inflammation in a fibrinous pericardium (Panel F,H) : (hematoxylin and eosin) and (Panel G) : (fils polarized). Visible granuloma (Panel F).

Endogenous T1\u03c1 cardiovascular magnetic resonance in hypertrophic cardiomyopathy

BackgroundHypertrophic cardiomyopathy (HCM) is characterized by increased left ventricular wall thickness, cardiomyocyte hypertrophy, and fibrosis. Adverse cardiac risk characterization has been performed using late gadolinium enhancement (LGE), native T1, and extracellular volume (ECV). Relaxation time constants are affected by background field inhomogeneity. T1ρ utilizes a spin-lock pulse to decrease the effect of unwanted relaxation. The objective of this study was to study T1ρ as compared to T1, ECV, and LGE in HCM patients.MethodsHCM patients were recruited as part of the Novel Markers of Prognosis in Hypertrophic Cardiomyopathy study, and healthy controls were matched for comparison. In addition to cardiac functional imaging, subjects underwent T1 and T1ρ cardiovascular magnetic resonance imaging at short-axis positions at 1.5T. Subjects received gadolinium and underwent LGE imaging 15–20 min after injection covering the entire heart. Corresponding basal and mid short axis LGE slices were selected for comparison with T1 and T1ρ. Full-width half-maximum thresholding was used to determine the percent enhancement area in each LGE-positive slice by LGE, T1, and T1ρ. Two clinicians independently reviewed LGE images for presence or absence of enhancement. If in agreement, the image was labeled positive (LGE + +) or negative (LGE −−); otherwise, the image was labeled equivocal (LGE + −).ResultsIn 40 HCM patients and 10 controls, T1 percent enhancement area (Spearman’s rho = 0.61, p < 1e-5) and T1ρ percent enhancement area (Spearman’s rho = 0.48, p < 0.001e-3) correlated with LGE percent enhancement area. T1 and T1ρ percent enhancement areas were also correlated (Spearman’s rho = 0.28, p = 0.047). For both T1 and T1ρ, HCM patients demonstrated significantly longer relaxation times compared to controls in each LGE category (p < 0.001 for all). HCM patients also showed significantly higher ECV compared to controls in each LGE category (p < 0.01 for all), and LGE −− slices had lower ECV than LGE + + (p = 0.01).ConclusionsHyperenhancement areas as measured by T1ρ and LGE are moderately correlated. T1, T1ρ, and ECV were elevated in HCM patients compared to controls, irrespective of the presence of LGE. These findings warrant additional studies to investigate the prognostic utility of T1ρ imaging in the evaluation of HCM patients.

Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary Background Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema. Purpose The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM). Methods A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age &amp;gt;18 years, in the athlete group &amp;gt;7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated. Results Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15 ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p &amp;lt; 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p &amp;lt; 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p &amp;lt; 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p &amp;lt; 0.01). Conclusion Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy. Abstract Figure. T1 mapping in HCM and athlete

Gender difference in extreme cardiac remodelling in endurance olympic athletes assessed by non-contrast CMR

Abstract Funding Acknowledgements Type of funding sources: None. Background Male and female athletes present difference spectrum of cardiac remodelling related to their sport activity. However data in elite female athletes are scarce and mainly limited to echocardiography evaluation. Purpose The aim of the study was to assess gender difference in extreme cardiac remodelling in Olympic athletes engaged in endurance sport assessed by non-contrast Cardiovascular Magnetic Resonance including Mapping. Methods Olympic athletes engaged in endurance sport (rowing, canoeing, mid/long distance swimming) were examined with history, physical examination, 12-lead and exercise electrocardiogram, and echocardiography as part of their evaluation prior the Olympic games (Tokyo 2020). Athletes with unremarkable evaluation were undergone to non-contrast CMR including Mapping. The following parameters were calculated: indexed left ventricle (LV) and right ventricle (RV) end-diastolic (EDVi) and end-systolic volumes (ESVi), stroke volume (SVi), ejection fraction (EF), left and right atria area (LAAi and RAAi), LV Mass (Massi) and maximum wall thickness (MWT), RV/LV EDV ratio, spericity index [SI=(long axis diameter/2)3 * 4,187], myocardial native T1 (nT1) and T2 Mapping. Results 51 caucasian elite athletes (without difference in term of age, years of training and hours of training/week) were enrolled and 59% were male. Male showed greater LV EDVi (123 ± 28 ml vs 103 ± 10, p = 0.003), ESVi (55 ± 14 ml vs 44 ± 7, p = 0.001), SVi (68 ± 15 ml vs 59 ± 7, p = 0.023), Massi (76 ± 19 vs 57 ± 10, p &amp;lt; 0.001), MWT (10 ± 1 mm vs 8 ± 1, p &amp;lt; 0.001) and RV EDVi (129 ± 48 ml vs 104 ± 13, p = 0.026), ESVi (57 ± 10 ml vs 45 ± 9, p &amp;lt; 0.001), SVi (68 ± 15 ml vs 59 ± 7, p = 0.018) compared to female, as expected. LVEF (p = 0.05) and RVEF (p = 0.17) did not show significant difference. Despite greater volumes, SI (43 ± 12% vs 44 ± 8, p = 0.8) and RV/LV EDV ratio (0.99 ± 0.05 vs 1 ± 0.05, p = 0.405) did not differ between male and female athletes, as well as LAAi (13 ± 3 cm2 vs 13 ± 1.5, p = 0.86) and RAAi (13 ± 1.9 vs 13 ± 18, p = 0.56). Native T1 mapping was lower in male compared with female (934 ± 21 ms vs 956 ± 33, p = 0.028) while T2 Map values were slightly higher (53 ± 3.9 ms vs 50 ± 3.8, p = 0.027) . Conclusions Male endurance Olympic athletes presented higher volumes and LV mass compared to their female counterparts, while atria dimension, systolic function and sphericity index did not differ. Ventricles showed balanced dilatation in both gender. Lower T1 value observed in male suggested cellular hypertrophy. Figure 1 showed CMR images in a male (top row) and a female (bottom row) Olympic athletes: 4 chamber end-diastolic and end-systolic frame and end-diastolic basal short axis (SAX) showed balanced dilatation. Graphs showed higher EDVi and Massi in male compared o female, no difference in sphericity index and lower native T1 mapping. Abstract Figure 1

Texture-based machine learning in LGE-CMRI for automatic scar assessment

Abstract Background Conventional methods for the estimation of infarct size by late-enhanced cardiac magnetic resonance imaging use analyzes from each slice which in turn is added to generate a volume. We present a novel method based on machine learning, called texture based probability mapping (TPM). TPM is based upon expressing the probability of scarring in a pixel based upon analysing textural information in patches around each pixel. Purpose To explore our method and assess its utility as a tool to scar size and compare it with four established methods. Methods In 54 patients with ischemic scars, our method was compared with four 2D methods. 2 patients were excluded due to low image quality and artefacts. The most basal and apical short axis image slices were exclude due to partial volume artefacts. Myocardial infarction (MI) size was estimated manually, and TPM performed. Cardiac segments were defined as myocardial regions with pixel probabilities within a specified range. By varying the lower probability threshold while keeping the upper threshold fixed at 1, different cardiac segments were defined. Using the Sørensen-Dice coefficient the optimal probability range with the highest correlation to manual estimation of infarct size was identified. Results TPM-range 0.341–1.0 is best correlated to manual demarcation (median Dice 0.70). The method demonstrated stronger correlations between scar size and left ventricular remodeling parameters (LV ejection fraction: r=−0.731, p&amp;lt;0.0005; LV end-diastolic volume: r=0.641, p&amp;lt;0.0005; LV end-systolic volume: r=0.672, p&amp;lt;0.0005) compared with manual method. Conclusion Using TPM, infarct size can be measured automatically without using signal intensity as a reference value. It is without the need for manual demarcation of the scar and is less time consuming and less vulnerable to interobserver variability. It has a strong correlation with left ventricular remodeling parameters crucial in guiding further medical therapy. The use of this method is however not primarily dedicated for scar size estimation, but a tool to evaluate different properties of the tissue that cannot be visualized by the naked eye. It's an important step towards better understanding of myocardial damage pattern causing ventricular arrhythmia and SCD. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Helse Vest

Structural and functional cardiac changes after transplantation: experiences of the first year of the prospective Heart-TIming CMR substudy

Abstract Background In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand cardiac temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018. Purpose In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using cardiac magnetic resonance. Methods As part of the study HTX patients underwent CMR at one, three, six and twelve months after HTX (n=49; 53±11y, 39 male). Cine images, T2-weighted, native T1 and T2 mapping, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 and 12 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=9). We evaluated the left (LV) and right ventricular (RV) ejection fractions (EF), volumes, masses (M) and the global LV strain values: longitudinal (GLS), circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the mechanical dispersion. In a basal short axis slice the native T1 and T2 mapping values were evaluated. We compared baseline CMR parameters to age and gender matched healthy controls (n=20; 48±10y, 16 male), and analyzed the temporal changes after HTX. Results Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower end-diastolic volumes (LVEDVi: 74±15 vs 89±13 ml/m2; RVEDVi: 72±16 vs 89±15 ml/m2 p&amp;lt;0.05), stroke volumes (LVSVi: 45±7 vs 55±8 ml/m2, RVSVi: 43±8 vs 54±8 ml/m2, p&amp;lt;0.0001), higher LVMi (63±2 vs 55±3 g/m2, p&amp;lt;0.05), increased SD of peak LS (14±2 vs 10±2, p&amp;lt;0.0001) and more pronounced mechanical dispersion (18±5 vs 12±4, p&amp;lt;0.0001). The native T1 mapping values were significantly higher in HTX pts (1007±40 vs 975±24 ms, p&amp;lt;0,01). Examining temporal changes in HTX pts we found a decrease in LVMi (66±14 vs 59±10 g/m2, p&amp;lt;0.01) already at three months. At 12 months LVMi decreased further, less negative GLS (−25±4 vs −20±4, p&amp;lt;0.01) and GCS (−38±7 vs −34±4, p&amp;lt;0.05), and lower SD of the peak LS (14±2 vs 11±2, p&amp;lt;0.01) were measured. Conclusions Understanding the temporal changes of cardiac mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts. Tissue specific information in HTX pts Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. Supported by the ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

The Acute Effects of Esmolol in Intact and Infarcted Myocardium–Experimental Study

Aim: Early intravenous use of b-blockers within the first hours of STEMI is less firmly established. The aim of this study was to evaluate the effect of esmolol on left ventricular (LV) haemodynamic, rotational and strain parameters in intact myocardium and early post an experimental acute anterior myocardial infarction (MI). Methods: In 20 healthy pigs LV torsional and strain parameters were calculated from basal and apical short axis epicardial planes with speckle tracking technique using EchoPAC platform. LV measurements at baseline and during esmolol infusion (0.5 mg/kg for 1 min, then 0.05 mg/kg/min for 5 min) were compared in intact myocardium and repeated without b-blocker and during esmolol infusion 2 hours post LAD ligation. Results: LV function was highly dependent on the esmolol infusion, in the intact and even more in the infarcted myocardium. LV ejection fraction, LV dP/dtmax and LV end-systolic pressure decreased significantly, a deterioration produced by the administration of esmolol. Torsion-twist and untwisting rate also presented significant reduction in correlation with ejection fraction and cardiac output, appearing to affect especially the apex torsional and strain parameters. Conclusion: Esmolol infusion significantly reduces LV haemodynamic, torsional and strain parameters in intact myocardium and early post MI. These results suggest that early intravenous use of esmolol in patients with STEMI is risky and it is prudent to wait for the patient to stabilize before starting esmolol.

Single-shot EPI for ASL-CMR.

To evaluate single-shot echo planar imaging (SS-EPI), as an alternative to snapshot balanced steady state free precession (bSSFP) imaging, for arterial-spin-labeled cardiac MR (ASL-CMR). This study presents a practical implementation SS-EPI tailored to the needs of ASL-CMR at 3T and demonstrates sequential multi-slice ASL with no increase in scan time. Reduced field of view SS-EPI was performed using a 2DRF pulse. A spin-echo was used with crushers optimized to maximize blood suppression and minimize myocardial signal loss, based on experiments in 4 healthy volunteers. SS-EPI was evaluated against the widely used bSSFP reference method in single-slice ASL-CMR in 4 healthy volunteers, during both systole and diastole. Sequential multi-slice ASL-CMR with SS-EPI was demonstrated during diastole (3 slices: basal, mid, and apical short-axis) and during systole (2 slices: mid and apical short-axis), in 3 volunteers. Global myocardial perfusion for diastolic SS-EPI (1.66 ± 0.73 mL/g/min) and systolic SS-EPI (1.50 ± 0.36 mL/g/min) were found to be statistically equivalent (2 one-sided test with a difference of 0.4 mL/g/min) to diastolic bSSFP (duration of 1 cardiac cycle, 1.60 ± 0.80 mL/g/min) with P-values of 0.022 and 0.031, respectively. Global myocardial perfusion for sequential multi-slice experiments was 1.64 ± 0.47, 1.34 ± 0.29, and 1.88 ± 0.58 for basal, mid, and apical SAX slices during diastole and was 1.61 ± 0.35, and 1.66 ± 0.49 for mid and apical slice during systole. These values are comparable to published ASL-CMR and positron emission tomography studies. SS-EPI is a promising alternative to bSSFP imaging for ASL-CMR and can potentially improve the spatial coverage of ASL-CMR by 3-fold during diastole and 2-fold during systole, without increasing scan time.

P823 Usefulness of myocardial deformation imaging for assessment and long - term prognosis in young patients with Kawasaki disease

Abstract Kawasaki disease is an autoimmune process, which characterizes with the engagement of arteries and especially - the coronary arteries of the heart.The aim of the study was to assess global and regional LV myocardial function and to predict the long-term prognosis of Kawasaki disease.Design and method: We analyzed 62 children (mean age 9,4 ±3,9 years ), 28 of them with a residual coronary aneurism and 20 healthy children ( mean age 9,6 ±4, 8). The myocardial deformation indexes of the LV – global and regional longitudinal, circumferential and radial stain were analyzed. The patients are divided into groups according to the type of treatment and the occurrence of complications - residual aneurysms. Apical, middle and basal short axis for 2D images were acquired (65 ± 7 frames/s) in addition to apical four, three and two-chamber views. Global and regional peak systolic strain - longitudinal, radial and circumferential of the LV was derived and the strain curves (eLL, eCC, eRR) were extracted using a commercial softwareResults: Global longitudinal strain measurements of the LV were non-significantly different between the Kawasaki group without an aneurysm and normals (GLS -19,81± 1,91% vs -19,69 ± 1,91%) In the group of Kawasaki with an aneurysm was found significantly reduced GLS compared to healthy patients (-17,25 ± 3.48% vs -19,69± 1,81%. ). Concerning the regional analysis,in the group with aneurysms, the radial, circumferential and longitudinal strain were significantly reduced, especially on the basal and middle LV-segments. Conclusion Decreased myocardial strain values are signs of regional hypokinesia with a possible local segmental ischemia in the group with coronary aneurysms on coronary artery and are marker for developing severe LV dysfunction in the future. The contribution in this study was the introduction of a new non-invasive assessment of myocardial function after Kawasaki disease, despite the apparently "normal" global systolic heart function. Global and regional myocardial strain 2D strain % Healthy controls Patients with Kawasaki disease and aneurysms Patients with Kawasaki disease without aneurysms 2Ds_rr 51.06 ± 4.95 37.24 ± 7.53* 41.91 ± 4.87 2Ds_cc -20.91 ± 0.76 -16.45 ± 3.01* -18.91 ± 2.73 2Ds_ll -19.69 ± 1.82 -17.25 ± 3.48* -19.81 ± 1.91 Basal level 2Ds_rr 2Ds_cc 2Ds_ll 52.03 ± 9.09 -20.68 ± 1.56 -19.74 ± 1.94 36.40 ± 12.57* -15.32 ± 2.81* -15.32 ± 2.81* 46.10± 8.37 -18.32 ± 2.01 -19.32 ± 0.97 Middle 2Ds_rr 2Ds_cc 2Ds_ll 49.54 ± 6.41 -21.3 ± 2.27 -20.92 ± 3.37 35.77 ± 9.26* -15.44 ± 3.04* -15.01 ± 2.79* 44.01 ± 10.12 -17.92 ± 1.11 -19.02 ± 1.31 Apical 2Ds_rr 2Ds_cc 2Ds_ll 51.30 ± 2.27 -21.30 ± 2.27 -20.92 ± 3.37 39.52 ± 12.93* -17.73 ± 4.45* -16.78 ± 4.49* 46.66± 8.57 -19.22 ± 1.87 -19.32 ± 1.01 * p &amp;lt; 0.01

P1465Artificial intelligence in echocardiography - Steps to automatic cardiac measurements in routine practice

Abstract Introduction The growth of artificial intelligence (AI) use in echocardiography over the past years has been exponential, proposing new paths to overcome inter-operator variability and experience of the operator. Even though the applications of AI are still in their infancy within the field of echocardiography, the potential of AI implies future directions and is eager to assist for accuracy and efficiency of manual tracings. Deep learning, a subset of machine learning algorithms, is gaining popularity in echocardiography as a state of the art in visual data analysis. Purpose To evaluate deep learning for two initial tasks in automated cardiac measurements: view recognition and end-systolic (ES) and end-diastolic (ED) frame detection. Methods A total of 230 patients' (with various indications for study) 2D echocardiography data was used to train and validate neural networks. Raw pixel data was extracted from EPIQ 7G, Vivid E95 and Vivid 7 imaging platforms. Images were labeled according to their view: parasternal long axis (PLA), basal short axis, short axis at mitral level, apical two, three and four chambers (A4C). Additionally, ES and ED frames were labeled for A4C and PLA views. Images were de-identified by applying black pixel masks to non-anatomical data and removing metadata. Convolutional Neural Network (CNN) architecture was used for the classification of 6 different views. A total of 34752 and 3972 (5792 and 662 per view) frames were used to train and validate the network, respectively. Long-term Recurrent Convolutional Network (LRCN) combining temporal and spatial cognition was used for ES and ED frame detection. A total of 195 and 35 sequences with a length of 92 frames were used to train the LRCN. Results CNN for view classification had an AUC of 0.95 (sensitivity 95%, specificity 97%). Accuracy was lower for visually similar views, namely apical three-chamber and apical two-chamber. Training for ES and ED detection was achieved when training LRCN for regression instead of classification of each frame. LRCN for cardiac cycle evaluation had an average Framed Difference (aFD) of 2.31 (SD±2.15) for ED and 1.97 (SD±2.04) frames for ES detection which corresponds to error rate of about 0.04 s. Conclusion Determining echocardiographic view and evaluating cardiac cycle are the first steps in automating cardiac measurements. We have demonstrated the potential of two deep learning algorithms in accomplishing these tasks. Initial results are promising for the development of neural networks for cardiac segmentation and measuring of anatomical structures.