Baseline Cardiac Magnetic Resonance Research Articles

Prognosis of myocarditis stratified by initial clinical presentation: Does “intermediate” risk still play a role?

Background/aimsMyocarditis is an inflammatory disease with diverse clinical presentations. It is known that low-risk patients have a good prognosis compared to high-risk patients. There are few data regarding the prognosis of intermediate-risk patients. This study aimed to analyze the long-term outcomes of patients with acute myocarditis with different risk profiles at presentation, focusing on the intermediate risk one. MethodsA retrospective multicenter study was conducted, enrolling patients who met the diagnostic criteria for clinically suspected myocarditis with acute presentation. Patients were stratified into high, intermediate and low risk, according to the classification proposed by Sinagra and his team. Cardiovascular adverse events (AEs) were assessed after a median follow-up of 19 months. Echocardiographic and cardiac magnetic resonance (CMR) parameters predictive of adverse events have been reported. ResultsWe enrolled 127 patients (mean age 30 ± 13 years; 103 men, 24 women). High-risk patients had a higher frequency of adverse events (80 %) compared to other groups (16 %–16 %, p < 0.0001). An association was observed between the number of segments with late gadolinium enhancement (LGE) at baseline CMR and the occurrence of adverse events (p < 0.0037). The sum of segments with LGE was statistically correlated with lower left ventricular GLS (p < 0.009). The number of segments with LGE that most accurately identified the occurrence of adverse events was 2.5 [AUC 0.5; p = 0.24]. ConclusionsOur study confirms the higher incidence of AE in the high group; the prognosis of patients at intermediate risk is not very different from those at low risk. It can be hypothesized that the extent of LGE at baseline is the main predictor of adverse events in patients at intermediate risk.

Clinical Significance of Myocardial Injury in Patients Hospitalized for COVID-19: A Prospective, Multicenter, Cohort Study.

Hospitalized COVID-19 patients with troponin elevation have a higher prevalence of cardiac abnormalities than control individuals. However, the progression and impact of myocardial injury on COVID-19 survivors remain unclear. This study sought to evaluate myocardial injury in COVID-19 survivors with troponin elevation with baseline and follow-up imaging and to assess medium-term outcomes. This was a prospective, longitudinal cohort study in 25 United Kingdom centers (June 2020 to March 2021). Hospitalized COVID-19 patients with myocardial injury underwent cardiac magnetic resonance (CMR) scans within 28days and 6months postdischarge. Outcomes were tracked for 12months, with quality of life surveys (EuroQol-5 Dimension and 36-Item Short Form surveys) taken at discharge and 6months. Of 342 participants (median age: 61.3 years; 71.1% male) with baseline CMR, 338 had a 12-month follow-up, 235 had a 6-month CMR, and 215 has baseline and follow-up quality of life surveys. Of 338 participants, within 12months, 1.2% died; 1.8% had new myocardial infarction, acute coronary syndrome, or coronary revascularization; 0.8% had new myopericarditis; and 3.3% had other cardiovascular events requiring hospitalization. At 6months, there was a minor improvement in left ventricular ejection fraction (1.8% ± 1.0%; P< 0.001), stable right ventricular ejection fraction (0.4% ± 0.8%; P = 0.50), no change in myocardial scar pattern or volume (P = 0.26), and no imaging evidence of continued myocardial inflammation. All pericardial effusions (26 of 26) resolved, and most pneumonitis resolved (95of 101). EuroQol-5 Dimension scores indicated an overall improvement in quality of life (P< 0.001). Myocardial injury in severe hospitalized COVID-19 survivors is nonprogressive. Medium-term outcomes show a low incidence of major adverse cardiovascular events and improved quality of life. (COVID-19 Effects on the Heart; ISRCTN58667920).

The effects of pregnancy in subjects with repaired tetralogy of Fallot

BackgroundPrevious reports reveal inconsistent findings of right ventricular (RV) changes following pregnancy in subjects with repaired tetralogy of Fallot (rTOF). MethodsA two-center, retrospective cohort study which included women with rTOF who completed pregnancy that were matched to nulliparous women with rTOF by age at the time of baseline cardiac magnetic resonance (CMR), RV ejection fraction (RVEF), and indexed RV end-diastolic volume (RVEDVi). Pre-pregnancy and postpartum cardiac magnetic resonance (CMR) were analyzed and compared to sequential CMR of nulliparous subjects with rTOF. ResultsThirty-six women with rTOF who completed pregnancy were matched to 72 nulliparous women with rTOF. Over a mean period of 3.1 years for the pregnancy group and 2.7 years for the comparison group, there was no significant change in the RVEDVi, RVEF, RV mass, pulmonary regurgitation severity, left ventricular (LV) volumes, LV ejection fraction (LVEF), or LV mass when comparing the baseline CMR and the follow-up CMR in either of the groups. There was a slight increase in RV indexed end-systolic volume (RVESVi) when comparing the baseline CMR and the follow-up CMR in the pregnancy group (68.93, SD 23.34 ml/m2 at baseline vs. 72.97, SD 25.24 mL/m2 at follow-up, P = .028). Using a mixed effects model for CMR parameters change over time; when adjusted for time between baseline and follow-up CMR there was no significant difference in rate of change between the pregnancy and comparison groups. ConclusionsMost ventricular remodeling parameters measured by CMR did not significantly change in subjects with rTOF who completed pregnancy or in nulliparous subjects with rTOF. In the pregnancy group, RVESVi is larger in those individuals who have undergone pregnancy without a significant change in ventricular function. These patients should be followed longitudinally to determine the long-term ventricular and clinical effects of pregnancy.

Cardiac magnetic resonance patterns of left ventricular remodeling in patients with severe aortic stenosis referred to surgical aortic valve replacement

Left ventricular (LV) hypertrophy is a common finding in patients with severe aortic stenosis (AS). Cardiac magnetic resonance (CMR) is the gold-standard technique to evaluate LV remodeling. Our aim was to assess the prevalence and describe the patterns of LV adaptation in AS patients before and after surgical aortic valve replacement (AVR). Prospective study of 130 consecutive patients (71y [IQR 68–77y], 48% men) with severe AS, referred for surgical AVR. Patterns of LV remodeling were assessed by CMR. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling. At baseline CMR study: mean LV indexed mass: 81.8 ± 26.7 g/m2; mean end-diastolic LV indexed volume: 85.7 ± 23.1 mL/m2 and median geometric remodeling ratio: 0.96 g/mL [IQR 0.82–1.08 g/mL]. LV hypertrophy occurred in 49% of subjects (concentric 44%; eccentric 5%). Both normal LV structure and concentric remodeling had a prevalence of 25% among the cohort; one patient had an adverse remodeling pattern. Asymmetric LV wall thickening was present in 55% of the patients, with predominant septal involvement. AVR was performed in 119 patients. At 3–6 months after AVR, LV remodeling changed to: normal ventricular geometry in 60%, concentric remodeling in 27%, concentric hypertrophy in 10%, eccentric hypertrophy in 3% and adverse remodeling (one patient). Indexes of AS severity, LV systolic and diastolic function and NT-proBNP were significantly different among the distinct patterns of remodeling. Several distinct patterns of LV remodelling beyond concentric hypertrophy occur in patients with classical severe AS. Asymmetric hypertrophy is a common finding and LV response after AVR is diverse.

Multiparametric Cardiovascular Magnetic Resonance in Nonhospitalized COVID-19 Infection Subjects: An Intraindividual Comparison Study.

To investigate intraindividual cardiac structural and functional changes before and after COVID-19 infection in a previously healthy population with a 3T cardiac magnetic resonance (CMR). A total of 39 unhospitalized patients with COVID-19 were recruited. They participated in our previous study as non-COVID-19 healthy volunteers undergoing baseline CMR examination and were recruited to perform a repeated CMR examination after confirmed COVID-19 infection in December 2022. The CMR parameters were measured and compared between before and after COVID-19 infection with paired t tests. The laboratory measures including myocardial enzymes and inflammatory indicators were also collected when performing repeated CMR. The median duration was 393 days from the first to second CMR and 26 days from clinical symptoms onset to the second CMR. Four patients (10.3%, 4/39) had the same late gadolinium enhancement pattern at baseline and repeated CMR and 5 female patients (12.8%, 5/39) had myocardial T2 ratio >2 (2.07 to 2.27) but with normal T2 value in post-COVID-19 CMR. All other CMR parameters were in normal ranges before and after COVID-19 infection. Between before and after the COVID-19 infection, there were no significant differences in cardiac structure, function, and tissue characterization, no matter with or without symptoms (fatigue, chest discomfort, palpitations, shortness of breath, and insomnia/sleep disorders) (all P >0.05). The laboratory measures at repeated CMR were in normal ranges in all participants. These intraindividual CMR studies showed unhospitalized patients with COVID-19 with normal myocardial enzymes had no measurable CMR abnormalities, which can help alleviate wide social concerns about COVID-19-related myocarditis.

The Prognostic Value of One-Year Changes in Biventricular Mechanics for Three-Year Survival in Patients with Precapillary Pulmonary Hypertension: A Cardiovascular Magnetic Resonance Feature Tracking Study.

Background and Objectives: The management of patients with pulmonary hypertension (PH) poses a considerable challenge. While baseline cardiac magnetic resonance imaging (cMRI) indices are recognized for survival prognosis in PH, the prognostic value of one-year changes in biventricular mechanics, especially as assessed using feature tracking (FT) technology, remains underexplored. This study aims to assess the predictive value of one-year change in cMRI-derived biventricular function and mechanics parameters, along with N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and six-minute walking test (6MWT) results for three-year mortality in precapillary PH patients. Materials and Methods: In this retrospective study, 36 patients diagnosed with precapillary pulmonary hypertension (mPAP 55.0 [46.3-70.5] mmHg, pulmonary capillary wedge pressure 10.0 [6.0-11.0] mmHg) were included. Baseline and one-year follow-up cMRI assessments, clinical data, and NT-proBNP levels were analyzed. FT technology was utilized to assess biventricular strain parameters. Patients were categorized into survival and non-survival groups based on three-year outcomes. Statistical analyses, including univariate logistic regression and Cox regression, were performed to identify predictive parameters. Results: The observed three-year survival rate was 83.3%. Baseline right ventricle (RV) ejection fraction (EF) was significantly higher in the survival group compared to non-survivors (41.0 [33.75-47.25]% vs. 28.0 [23.5-36.3]%, p = 0.044), and values of ≤32.5% were linked to a 20-fold increase in mortality risk. RV septum longitudinal strain (LS) and RV global LS exhibited significant improvement over a one-year period in the survival group compared to the non-survival group (-1.2 [-6.4-1.6]% vs. 4.9 [1.5-6.7]%, p = 0.038 and -3.1 [-9.1-2.6]% vs. 4.5 [-2.1-8.5]%, p = 0.048, respectively). Declines in RV septum LS by ≥2.95% and in RV GLS by ≥3.60% were associated with a 25-fold and 8-fold increase in mortality risk, respectively. Conclusions: The decrease in right ventricular septal and global longitudinal strain over a one-year period demonstrates a significant predictive value and an association with an increased three-year mortality risk in patients with precapillary PH.

Multiparametric Monitoring of Disease Progression in Contemporary Patients with Wild-Type Transthyretin Amyloid Cardiomyopathy Initiating Tafamidis Treatment.

Recently, a disease modifying therapy has become available for transthyretin amyloid cardiomyopathy (ATTR-CM). A validated monitoring concept of treatment is lacking, but a current expert consensus recommends three clinical domains (clinical, biomarker and ECG/imaging) assessed by several measurable features to define disease progression. We retrospectively analyzed data of wild-type ATTR-CM patients initiating tafamidis therapy assessed within our local routine protocol at baseline and 6-months follow-up with respect to the frequency of values beyond the proposed thresholds defining disease progression. Additionally, associations of cardiac magnetic resonance (CMR) tomography with clinical domains were examined within a subgroup. Sixty-two ATTR-CM patients were included (88.7% male, mean age 79 years). In total, 16.1% of patients had progress in the clinical and functional domain, 33.9% in the biomarker domain and 43.5% in the imaging/electrocardiography (ECG) domain, with the latter driven by deterioration of the diastolic dysfunction grade and global longitudinal strain. In total, 35.5% of patients showed progress in none, 35.5% in one, 29.0% in two and no patient in three domains, the latter indicating overall disease progression. A subgroup analysis of twenty-two patients with available baseline and follow-up CMR data revealed an increase in CMR-based extracellular volume by more than 5% in 18.2% of patients, with no significant correlation with progress in one of the clinical domains. We provide first frequency estimates of the markers of disease progression according to a recent expert consensus statement, which might help refine the multiparametric monitoring concept in patients with ATTR-CM.

Baseline predictors of final infarct size in patients with ST elevation myocardial infarction undergoing primary PCI

Abstract Background In patients with coronary artery disease, the presence and extent of myocardial scar determined from cardiac magnetic resonance (CMR) imaging have recognized associations with major adverse cardiac events. Therefore, in patients presenting with ST elevation myocardial infarction (STEMI), early prediction of final infarct size (IS) has important prognostic and therapeutic implications. Purpose We sought to determine the predictors of final IS from baseline clinical, laboratory, and CMR imaging variables in patients presenting with STEMI and undergoing successful primary PCI (pPCI). Methods After successful pPCI, 76 STEMI patients underwent baseline (within 48-hours) and 3-months follow-up CMR imaging. The baseline CMR study was used to measure left ventricular (LV) volumes, ejection fraction (EF), and global longitudinal strain (GLS), the latter calculated using feature tracking from cine images. Final IS was measured in the 3-months follow up study using signal intensity quantification by the full width at half maximum method from late gadolinium enhancement images and expressed as a percentage of the total LV mass. Serum ST2 was drawn within 48 hours of STEMI presentation. Maximum values of ECG ST elevation prior to pPCI and serum Troponin I during index hospitalization were measured. Non-collinear baseline variables deemed significantly associated with the final IS on univariable linear regression and captured in all patients were entered into a multivariable model, adjusting for age and sex. Results Mean age was 54.1±10.9 years, 64 patients (78%) being males. Mean LV EF was 43.5±9.8%. Univariable predictors of final IS included hypertension, baseline maximum troponin, ST2, maximum ST elevation, LV volumes and EF, GLS, total angiographic procedure time, the presence of multi-vessel CAD, use of thrombectomy, TIMI flow and myocardial blush grades at baseline and after wiring, and prescription of loop diuretics and potassium-sparing diuretics on discharge (Table 1). A final multivariable linear model was constructed including age, sex, maximum troponin, maximum ST elevation, ST2, LV EF and GLS. In this model, baseline LV EF, maximum troponin, and maximum ST elevation remained independently associated with the final IS. Respective beta coefficients [95% CI] were -0.63 [-1- (-0.26)], 0.22 [0.11-0.33], and 0.90 [0.22-1.58]; p=0.001, &amp;lt;0.001, and 0.01) (Table 2; adjusted R2=0.6, p&amp;lt;0.001). ST2 and GLS were no longer associated with the IS. Conclusion After successful pPCI, baseline LV EF, maximum troponin I, and maximum ST elevation were independent predictors of final IS. These simple markers can identify patients at high risk of final IS who might benefit from advanced therapeutics. Future studies are warranted to confirm the prognostic value of risk scores incorporating these markers. Advanced laboratory (ST2) and imaging (strain) markers were not independently associated with IS.

Myocardial structural and functional changes in cardiac amyloidosis - insights from a prospective observational patient registry

Abstract Background Within the last decade, cardiac amyloidosis (CA) has been acknowledged as a significant cause of heart failure and patients who are affected face a dismal prognosis, especially in later stages of the disease. The pathophysiological hallmark of cardiac amyloidosis (CA) is the deposition of amyloid within the myocardium. Consequently, extracellular volume (ECV) of affected patients increases. However, studies on ECV progression over time and its' impact on prognosis are lacking. Objectives We aimed to investigate the progression of ECV and its prognostic impact in CA patients. Methods Serial cardiac magnetic resonance (CMR) examinations, including ECV quantification were performed in consecutive CA patients. Results Between 2012 and 2021, 103 CA patients underwent baseline and follow-up CMR, including ECV quantification. Median ECVs at baseline of the total (n = 103), transthyretin [(ATTR) n = 80], and [light chain (AL) n = 23] CA cohorts were 48.0%, 49.0%, and 42.6%. During a median follow-up period of 12 months, ECV increased significantly in all cohorts (48.0% to 50.5%, p&amp;lt;0.001; 49.0% to 50.5%, p&amp;lt;0.001; 42.6% to 50.6%, p = 0.026). Separate analyses for treatment-naïve (n = 14) and treated (n = 66) ATTR patients revealed that the median change of ECV from baseline to follow-up was significantly higher among untreated patients (5.5% versus 2.7%, p = 0.035). Survival analyses demonstrated that median change of ECV was an independent (adjusted for troponin t and NT-proBNP) predictor of outcome in all CA cohorts [total: hazard ratio (HR): 1.114, 95% confidence-interval (CI): 1.045 – 1.189, p&amp;lt;0.001; ATTR: HR: 1.099, 95% CI: 1.014 – 1.192, p = 0.022; AL: HR: 1.142, 95% CI: 1.006 – 1.297, p = 0.040]. Conclusions The present study demonstrates that ECV, quantified by CMR T1 mapping, increases significantly in CA patients over the course of 12 months. While ECV increased, irrespective of amyloid type our analyses showed the highest increase among untreated ATTR patients. Moreover, the change of ECV was an independent predictor of adverse outcomes in AL, as well as ATTR patients emphasizing the usefulness of CMR T1 mapping in the management of CA patients.Figure 1.Dot PlotsFigure 2.Kaplan Meier Curves

Cardiac CARE study: How the ESC Cardio-Oncology guidelines fo 2022 affect the study population

Abstract Introduction The new 2022 ESC Guidelines in Cardio-Oncology focused on cancer therapy-related cardiac dysfunction (CT-RCD), with the formal introduction of biomarkers in the classification and risk stratification of CTR-CD in addition to structural imaging . We here, investigated how these changes affect the classification of patients in the Cardiac CARE study and the value of high sensitivity troponin I (hSTrop-I). Methods The Cardiac CARE study prospectively recruited 191 patients who underwent anthracycline therapy for breast cancer or non-Hodgkin’s lymphoma. All patients underwent regular hSTrop-I levels throughout their anthracycline therapy as well as a baseline and 6-month cardiac magnetic resonance scans including assessment of left ventricular ejection fraction and global longitudinal strain. A post-hoc analysis assessed the association between hSTrop-I and the development of cardiac dysfunction (defined as a reduction in left ventricular ejection fraction &amp;lt;50% or a reduction in GLS by &amp;gt;15%) using logistic regression with data corrected for age and gender. In addition, receiver operator curves (ROC) were drawn and area under the curve (AUC) analysis was performed to assess the value of hSTrop-I as an addition to the classification model. Finally, to compare our data with the new guidelines, a confusion matrix was performed. Results 11 patients were diagnosed as having cardiotoxicity in the Cardiac CARE study but using the 2022 ESC guidelines in Cardio-Oncology, 53 patients were re-classified into the ‘asymptomatic mild cardiotoxicity’ group (95% CI of 0.5162 and 0.6823; kappa value 0.157). Using a logistic regression model, a difference in hSTrop-I measured at the first cycle of anthracycline therapy had an odds ratio of 1.37 (95% CI 0.37-5.10) which when corrected for age dropped to 1.18 (95% CI of 0.28-5.01) and with combined age and sex correction, fell further, to 0.83 (95% CI of 0.12 and 5.56). A ROC analysis looking at the performance of hSTrop-I at predicting cardiac dysfunction demonstrated an area under the curve of 0.605 and when corrected for age and sex, was 0.640. Conclusion The addition of cardiac biomarkers to the new classification, significantly reclassified 53 of 191 (27.7%) of patients who were previously normal, to having asymptomatic mild cancer therapy-related cardiac dysfunction, mostly due to the inclusion of hSTrop I. HSTrop-I prior to anthracycline treatment was not a robust predictor of the development of anthracycline-induced cardiotoxicity in our cohort of patients. Of note, the Cardiac CARE patients are a low-risk group of patients and follow-up data is limited to 6 months.

Abstract 11536: Cardiac Magnetic Resonance Imaging Paralleled Recurrent Pericarditis Clinical Response to Rilonacept Treatment Over 18 Months: A RHAPSODY Subgroup Analysis

Introduction: Rilonacept treatment in RHAPSODY resolved active pericarditis recurrences, and long-term treatment led to sustained risk reduction. Prior analysis linked greater baseline Late Gadolinium Enhancement (LGE), with more rapid recurrence upon rilonacept suspension after 12 weeks of treatment. Serial cardiac magnetic resonance (CMR) imaging (T2-STIR, LGE) enabled longitudinal assessment for tracking clinical improvement, guiding decision-making, and predicting patient outcomes after treatment cessation. Methods: At the long-term extension (LTE) 18-month decision milestone (18MDM), investigators chose, based on clinical status, to continue rilonacept, suspend rilonacept/observe, or discontinue the LTE. An imaging core lab blinded to clinical data measured pericardial thickness and graded pericardial edema (T2-STIR) and LGE at baseline and 18MDM. Pericarditis recurrence was assessed clinically following rilonacept suspension. Results: Baseline and 18MDM CMRs were available for 13 patients. Reductions in pericardial thickness, T2-STIR, and LGE from baseline to 18MDM while on treatment are provided in Figure . CMRs were obtained in 7/8 patients suspending rilonacept at 18MDM: LGE was none/trace, and T2-STIR was negative; yet, 5/7 (71%) had pericarditis recurrence within 1-4 months of rilonacept suspension despite prophylactic colchicine (n=2). Conclusions: Continued clinical improvement during prolonged rilonacept treatment corresponded with improvement on CMR, including reduced pericardial thickness, resolution of pericardial edema on T2-STIR, and resolution of LGE. Negative/trace LGE at 18MDM while on treatment did not predict absence of pericarditis recurrence upon subsequent rilonacept suspension in this size-limited subgroup. Larger prospective studies examining CMR parameters in guiding RP treatment duration decisions and informing associated clinical outcomes are warranted.

Abstract 16062: Acute Myocarditis and Pericarditis in Post-Acute Sequelae of COVID-19: Initial Insights From the IMPACT-COVID-19 Study

Introduction: Myocarditis and/or pericarditis were reported in patients with Post-Acute Sequelae of COVID-19 (PASC). Goals: We aim to determine the prevalences, risk factors, and discriminative values of inflammatory biomarkers for acute myocarditis/pericarditis in patients with PASC. Methods: IMPACT-COVID-19 is an ongoing prospective longitudinal cohort enrolling adults with PASC and at least one symptom suggestive of potential cardiac disorder (dyspnea, palpitation, chest pain and dizziness) in Quebec, Canada (years 2021-ongoing). We obtained baseline inflammatory, cardiac biomarkers, electrocardiograms, echocardiograms, and cardiac magnetic resonance imaging (CMR). We defined myocarditis/pericarditis as either 1) positive Lake Louise criteria on CMR, 2) pericardial effusion or 3) chest pain with elevated cardiac biomarkers or inflammatory biomarkers. Results: The following results were based on the initial 256 patients enrolled (with a median of 279 days after their initial COVID-19 infection). Most were female (73%), and White (86%) with a mean age of 45 years. Seventy-six patients (30%) had acute myocarditis and/or pericarditis. One hundred and three patients (40%) had an emergency room (ER) visit for the index COVID infection and this was associated with an increased risk of myocarditis/ pericarditis: (odds ratio: 2.39 (95% confidence intervals: 1.21, 4.72). The ESR was elevated in patients with myocarditis/pericarditis compared to patients without myocarditis/pericarditis (18 mm/h vs 12 mm/h; p:0.02). There was no observed difference in CRP (1.85 mg/L for patients with myocarditis/pericarditis versus 1.54 mg/L for patients without myocarditis/pericarditis, p:0.51). ROC c-statistics were 0.61 for ESR and 0.49 for CRP. An ESR of ≥14 mm/h has the best predictive value for myo/pericarditis. Conclusions: Our findings suggest that clinicians should be aware that patients with PASC, especially those who required an ER visit for their COVID-19 infection, are at increased risk for acute myocarditis/pericarditis. ESR should also be considered in the diagnostic tests for PASC-related myocarditis/pericarditis.

Tafamidis decreased cardiac amyloidosis deposition in patients with Ala97Ser hereditary transthyretin cardiomyopathy: a 12-month follow-up cohort study

BackgroundTransthyretin cardiac cardiomyopathy (ATTR-CM) is a rare but life-threatening disease. Tafamidis is an effective treatment for patients with ATTR-CM, however its long-term effects on cardiac remodeling and cardiac amyloid deposition are unknown. This study aimed to used cardiac magnetic resonance (CMR) to investigate the effects of tafamidis on patients with hereditary A97S ATTR-CM.MethodsWe retrospectively analyzed a prospective cohort of ATTR-CM patients, including 14 with hereditary A97S ATTR-CM and 17 healthy controls with baseline CMR data. All ATTR-CM patients received tafamidis treatment and received CMR with extracellular volume (ECV) at baseline and after 1 year of follow-up.ResultsBaseline N-terminal pro-B-type natriuretic peptide, left ventricular (LV) mass, LV ejection fraction, global radial, circumferential and longitudinal strain, T1 mapping and ECV were significantly worse in the patients with ATTR-CM compared with the healthy controls. After 1 year of tafamidis treatment, ECV decreased from 51.5 ± 8.9% to 49.0 ± 9.4% (P = 0.041), however there were no significant changes in LV mass, LV ejection fraction, global radial strain, global circumferential strain, global longitudinal strain and T1 mapping.ConclusionsAfter a one-year treatment period, tafamidis exhibited subtle but statistically significant reductions in ECV, potentially indicating a decrease in amyloid deposition among patients diagnosed with hereditary A97S ATTR-CM.

Contrast-enhanced cardiac MRI is superior to non-contrast mapping to predict left ventricular remodeling at 6 months after acute myocardial infarction

ObjectivesParametric mapping constitutes a novel cardiac magnetic resonance (CMR) technique enabling quantitative assessment of pathologic alterations of left ventricular (LV) myocardium. This study aimed to investigate the clinical utility of mapping techniques with and without contrast agent compared to standard CMR to predict adverse LV remodeling following acute myocardial infarction (AMI).Materials and methodsA post hoc analysis was performed on sixty-four consecutively enrolled patients (57 ± 12 years, 54 men) with first-time reperfused AMI. Baseline CMR was obtained at 8 ± 5 days post-AMI, and follow-up CMR at 6 ± 1.4 months. T1/T2 mapping, T2-weighted, and late gadolinium enhancement (LGE) acquisitions were performed at baseline and cine imaging was used to determine adverse LV remodeling, defined as end-diastolic volume increase by 20% at 6 months.ResultsA total of 11 (17%) patients developed adverse LV remodeling. At baseline, patients with LV remodeling showed larger edema (30 ± 11 vs. 22 ± 10%LV; p < 0.05), infarct size (24 ± 11 vs. 14 ± 8%LV; p < 0.001), extracellular volume (ECVinfarct; 63 ± 12 vs. 47 ± 11%; p < 0.001), and native T2infarct (95 ± 16 vs. 78 ± 17 ms; p < 0.01). ECVinfarct and infarct size by LGE were the best predictors of LV remodeling with areas under the curve (AUCs) of 0.843 and 0.789, respectively (all p < 0.01). Native T1infarct had the lowest AUC of 0.549 (p = 0.668) and was inferior to edema size by T2-weighted imaging (AUC = 0.720; p < 0.05) and native T2infarct (AUC = 0.766; p < 0.01).ConclusionIn this study, ECVinfarct and infarct size by LGE were the best predictors for the development of LV remodeling within 6 months after AMI, with a better discriminative performance than non-contrast mapping CMR.Clinical relevance statementThis study demonstrates the predictive value of contrast-enhanced and non-contrast as well as conventional and novel CMR techniques for the development of LV remodeling following AMI, which might help define precise CMR endpoints in experimental and clinical myocardial infarction trials.Key Points• Multiparametric CMR provides insights into left ventricular remodeling at 6 months following an acute myocardial infarction.• Extracellular volume fraction and infarct size are the best predictors for adverse left ventricular remodeling.• Contrast-enhanced T1 mapping has a better predictive performance than non-contrast standard CMR and T1/T2 mapping.

Magnetic resonance detection of advanced atrial cardiomyopathy increases the risk for atypical atrial flutter occurrence following atrial fibrillation ablation.

Recurrence of arrhythmia after catheter ablation of atrial fibrillation (AF) in the form of atypical atrial flutter (AFL) is common among a significant number of patients and often requires redo ablation with limited success rates. Identifying patients at high risk of AFL after AF ablation could aid in patient selection and personalized ablation approach. The study aims to assess the relationship between pre-existing atrial cardiomyopathy and the occurrence of AFL following AF ablation. We analysed a cohort of 1007 consecutive AF patients who underwent catheter ablation and were included in a prospective registry. Patients who did not have baseline cardiac magnetic resonance imaging and late gadolinium enhancement (LGE-CMR) or did not experience any recurrences were excluded. A total of 166 patients were included gathering 56 patients who underwent re-ablation due to AFL recurrences and 110 patients who underwent re-ablation due to AF recurrences (P = 0.11). A multiparametric assessment of atrial cardiomyopathy was based on basal LGE-CMR, including left atrial (LA) volume, LA sphericity, and global and segmental LA fibrosis using semiautomated post-processing software. Out of the initial cohort of 1007 patients, AFL and AF occurred in 56 and 110 patients, respectively. An age higher than 65 [odds ratio (OR) = 5.6, 95% confidence interval (CI): 2.2-14.4], the number of previous ablations (OR = 3.0, 95% CI: 1.2-7.8), and the management of ablation lines in the index procedure (OR = 2.5, 95% CI: 1.0-6.3) were independently associated with AFL occurrence. Furthermore, several characteristics assessed by LGE-CMR were identified as independent predictors of AFL recurrence after the index ablation for AF, such as enhanced LA sphericity (OR = 1.3, 95% CI: 1.1-1.6), LA global fibrosis (OR = 1.03, 95% CI: 1.01-1.07), and increased fibrosis in the lateral wall (OR = 1.03, 95% CI: 1.01-1.04). Advanced atrial cardiomyopathy assessed by LGE-CMR, such as increased LA sphericity, global LA fibrosis, and fibrosis in the lateral wall, is independently associated with arrhythmia recurrence in the form of AFL following AF ablation.

Baseline native T1 values are associated with adverse outcome in a newly diagnosed, hospitalised heart failure patient population

Abstract Funding Acknowledgements Type of funding sources: None. Background Tissue characterisation by T1 mapping on Cardiac Magnetic Resonance (CMR) imaging is a non-invasive assessment of diffuse cardiac fibrosis and has been shown to predict outcome in Heart Failure (HF). Purpose There is a need for improved risk stratification that delivers more personalised care for HF patients. We conducted the first prospective study to investigate novel CMR tissue characterisation biomarkers and correlate to adverse outcome, in a cohort of patients hospitalised with a new HF diagnosis. Methods This was single centre observational study. Inclusion criteria were admission with signs and symptoms of HF, and LVEF ≤50% or elevated plasma NTproBNP and being treated with intravenous furosemide. 43 consecutive eligible participants were included and underwent comprehensive CMR to establish anatomy, function and myocardial tissue characteristics during their presentation admission. Participants were managed according to best practice HF guidelines and underwent reviews at 6, 12–18 and 24–30 months. All clinically relevant event data e.g. death and rehospitalisation were recorded. Baseline CMR volumes, function, presence of Late Gadolinium Enhancement (LGE) and T1 mapping values were compared between the adverse event group and no adverse event group. ‘Adverse event’ was defined as all-cause mortality or HF hospitalisation. Results The median follow-up of 43 participants was 24.4 months. 41 (95%) were diagnosed with HF with reduced EF and 2 (5%) with HF with preserved Ejection Fraction. Baseline clinical, biochemical characteristics and NYHA class were similar between the adverse event and no adverse event groups. There was no significant difference between baseline LVEF (37% vs. 23%; p = 0.339) or NTproBNP levels (4948 vs.5456; p = 0.929) between groups. There was high uptake of HF medical therapy in both groups. (Table 1) 9 participants (21%) experienced adverse events. There was a significantly higher proportion of Ischaemic Cardiomyopathy in the adverse event group (67% vs. 18%; p = 0.008) with lower indexed LV volumes and mass. Native septal T1 (ms) was significantly higher in the adverse event group compared with the no adverse event group (1035 vs.996 p = 0.045). (Table 1) Receiver Operating Characteristic (ROC) analysis indicated a Native T1 cut-off value of 1022ms as most sensitive and specific. Kaplan-Meier survival analysis comparing those with Native T1 &amp;lt;1022ms and those with Native T1 &amp;gt;1022ms on their baseline CMR showed an adverse event-free survival benefit favouring the lower T1 value group (HR 11.4, p = 0.003 - Figure 1). Conclusions In a cohort of all-comer hospitalised patients with a new diagnosis of HF, followed up over a 24-month period, there was a high rate of adverse events. A higher native T1 value on baseline CMR was associated with worse outcome in terms of all-cause mortality or HF hospitalisation.

Clinical and cardiac magnetic resonance profile of patients with COVID-19 vaccine-related myocarditis compared with other acute myocarditis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Cardiology Society, Cardiac Imaging Association. Grant for short extern fellowship in national centers. Background Reports have suggested an association between the development of myocarditis and mRNA vaccines against COVID-19 coronavirus disease. Cardiac magnetic resonance (CMR) findings in this setting have not been widely explored. Purpose The present study explores the clinical profile and CMR imaging findings in patients with a diagnosis of myocarditis during the period of 1 month after COVID-19 vaccination compared to non-related myocarditis during the same period. Methods All patients who underwent a CMR for suspected myocardial infarction with non-obstructive coronary arteries (MINOCA) during a period of 1 year from June 2021 to June 2022 were retrospectively evaluated. Myocarditis was defined by modified Lake Louise criteria (mLLC) and vaccine-related myocarditis was defined as a myocarditis episode in the period of 1 month after vaccination. Electronic medical records were analyzed to collect data on baseline clinical variables, CMR features and clinical events. Results A total of 118 consecutive patients undergoing a CMR for suspected MINOCA were included in the study of whom 48 (40,7%) fulfilled mLLC for myocarditis, of those, 15 cases (31,25%) were vaccine-related myocarditis. Both related and non-vaccine related myocarditis were more frequent among men and there were no differences in cardiovascular risk factors or baseline comorbidities between groups. CMR findings showed that vaccine-related myocarditis had similar LVEF and RVEF compared to other myocarditis and there were no differences in native T1, native T2 or extracellular volume (ECV). (Table 1). Edema in non-vaccine related myocarditis was more frequently observed in inferolateral mid and basal segments (segment 11) whilst in vaccine-related myocarditis edema was more frequently observed in inferoseptal mid segment (segment 9). There were no differences in the localization of the late gadolinium enhancement (LGE). (Table 2.) CMR follow-up was performed in 30 patients between 6 to 8 months after admission, showing LGE persistence without edema in 70% of non-vaccine related patients and 77,8% of vaccine-related patients. There were only 2 myocarditis recurrences. During the clinical follow up there were no deaths or ventricular arrhythmias, there were 3 hospital readmissions, 2 of them for a new myocarditis episode and 1 due to an unrelated myocardial infarction. Conclusions Vaccine-related myocarditis represented a significant proportion of new myocarditis diagnosis from June 2021 and June 2022. There were no differences in baseline characteristics, index CMR and CMR follow-up features between both subtypes. Clinical follow up of vaccine-related myocarditis showed no important events.

Late gadolinium enhancement persistence in early cardiac magnetic resonance follow-up after acute myocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Multiparametric cardiac magnetic resonance (CMR) evaluation with modified Lake Louise criteria (mLLC) is the gold standard non-invasive test for the diagnosis of acute myocarditis. Although CMR in the follow-up may inform of edema resolution and myocardial fibrosis there is a lack of consensus on the optimal time interval to perform it and the clinical and prognostic differences between patients with complete resolution and those who present late gadolinium enhancement (LGE) persistence. Purpose To describe the clinical profile, CMR findings, early CMR follow-up and clinical events in patients with acute myocarditis focusing on the differences between patients who present complete LGE resolution versus patients with LGE persistence. Methods All patients who underwent a CMR for a suspected myocarditis during a period of 1 year from June 2021 to June 2022 were retrospectively evaluated. Those with a confirmed myocarditis by mLLC and a follow-up CMR were included. Electronic medical records were analyzed to collect data on baseline clinical variables, CMR features and follow-up events. Follow-up CMR was performed on follow-up based on clinician’s criteria. Results A total of 27 patients fulfilled mLLC for myocarditis during the period of study and had a follow-up CMR. The mean time to first CMR control was 186 +/- 95 days (6,2 months). Of those 23 (85.2%) presented persistent LGE enhancement and 4 of them presented a complete resolution of LGE. There were no statistically significant differences between groups although patients with complete LGE resolution tend to be younger. There were no differences between groups in terms of LVEF and RVEF. Patients with persistent LGE in the follow-up tend to have higher edema and LGE extension during the acute myocarditis episode, being the LGE difference statistically significant. In the follow up CMR almost all patients presented edema resolution and although the majority of patients (85.2%) presented LGE persistence they presented a trend to a decrease of affected segments (4.4 to 3.1 after mean time of 6 months). There were no differences in clinical events between groups in terms of death, admissions, ventricular arrhythmias and new episodes of myocarditis, patients with persistent LGE tend to have more visits for unresolved chest pain. Conclusions The majority of patients with a confirmed acute myocarditis had edema resolution and LGE persistence after 6 months. There were no differences in clinical events during follow-up. Follow up CMR before 6 months can prove resolving edema but LGE persistance is common. Further studies are needed to define the optimal interval to perform CMR after the index event.

Multiparametric cardiac magnetic resonance reveals persistent myocardial inflammation in patients with exertional heat illness.

To explore the clinical potential of multiparametric cardiac magnetic resonance (CMR) in evaluating myocardial inflammation in patients with exertional heat illness (EHI). This prospective study enrolled 28 males with EHI (18 patients with exertional heat exhaustion (EHE) and 10 with exertional heat stroke (EHS)) and 18 age-matched male healthy controls (HC). All subjects underwent multiparametric CMR, and 9 patients had follow-up CMR measurements 3months after recovery from EHI. CMR-derived left ventricular geometry, function, strain, native T1, extracellular volume (ECV), T2, T2*, and late gadolinium enhancement (LGE) were obtained and compared among different groups. Compared with HC, EHI patients showed increased global ECV, T2, and T2* values (22.6% ± 4.1 vs. 19.7% ± 1.7; 46.8ms ± 3.4 vs. 45.1ms ± 1.2; 25.5ms ± 2.2 vs. 23.8ms ± 1.7; all p < 0.05). Subgroup analysis showed that ECV was higher in the EHS patients than those in EHE and HC groups (24.7% ± 4.9 vs. 21.4% ± 3.2, 24.7% ± 4.9 vs. 19.7% ± 1.7; both p < 0.05). Repeated CMR measurements at 3months after baseline CMR showed persistently higher ECV than HC (p = 0.042). With multiparametric CMR, EHI patients demonstrated increased global ECV, T2, and persistent myocardial inflammation at 3-month follow-up after EHI episode. Therefore, multiparametric CMR might be an effective method in evaluating myocardial inflammation in patients with EHI. This study showed persistent myocardial inflammation after an exertional heat illness (EHI) episode demonstrated by multiparametric CMR, which is a potential promising method to evaluate the severity of myocardial inflammation and guide return to work, play, or duty in EHI patients. • EHI patients showed an increased global extracellular volume (ECV), late gadolinium enhancement, and T2 value, indicating myocardial edema and fibrosis. • ECV was higher in the exertional heat stroke patients than exertional heat exhaustion and healthy control groups (24.7% ± 4.9 vs. 21.4% ± 3.2, 24.7% ± 4.9 vs. 19.7% ± 1.7; both p < 0.05). • EHI patients showed persistent myocardial inflammation with higher ECV than healthy controls 3months after index CMR (22.3% ± 2.4 vs. 19.7% ± 1.7, p = 0.042).

Optimizing Arteriovenous Fistula Care in Kidney Transplant Recipients: A Complex Task.

Optimizing Arteriovenous Fistula Care in Kidney Transplant Recipients: A Complex Task.