Cardiac Magnetic Resonance Results Research Articles

CMR based measurement of aortic stiffness, epicardial fat, left ventricular myocardial strain and fibrosis in hypertensive patients

IntroductionA combined assessment of different parameters of cardiovascular (CV) risk and prognosis can be supportive and performed with cardiac magnetic resonance (CMR). Aortic stiffness, epicardial fat volume (EFV), left ventricular (LV) strain and fibrosis were evaluated within a single CMR examination and results were related to the presence of hypertension (HTN) and diabetes mellitus (DM). Methods20 healthy controls (57.2 ± 8.2 years(y); 26.2 ± 3.9 kg/m2), 31 hypertensive patients without DM (59.6 ± 6.7 y; 28.4 ± 4.7 kg/m2) and 12 hypertensive patients with DM (58.8 ± 9.9y; 30.7 ± 6.3 kg/m2) were examined at 1.5Tesla. Aortic stiffness was evaluated by calculation of aortic pulse wave velocity (PWV), EFV by a 3D-Dixon sequence. Longitudinal & circumferential systolic myocardial strain (LS; CS) were analyzed and T1-relaxation times (T1) were determined to detect myocardial fibrosis. ResultsEFV was highest in hypertensive patients with diabetes (78.4 ± 28.0 ml/m2) followed by only hypertensive patients (64.2 ± 27.3 ml/m2) and lowest in controls (50.3 ± 22.7 ml/m2; p < 0.05). PWV was higher in hypertensive patients with diabetes (9.8 ± 3.3 m/s) compared to only hypertensive patients (8.6 ± 1.7 m/s; p < 0.05) and to controls (8.1 ± 1.9 m/s; p < 0.05). LS&CS were worse in hypertensive patients with diabetes (LS:-20.9 ± 5.1% and CS: −24.4 ± 5.7%) compared to both only hypertensive patients (LS: −24.7 ± 4.6%; CS: −27.1 ± 5.0%; p < 0.05) and to controls (LS: −25.5 ± 3.8; CS: −28.3 ± 4.1%; p < 0.05). Both hypertensive groups with and without DM had higher T1́s (994.0 ± 43.2 ms; 991.6 ± 35.5 ms) than controls (964.6 ± 40.3 ms; p < 0.05). ConclusionCMR revealed increased aortic stiffness and EFV in hypertensive patients, which were even higher in the presence of DM. Also signs of LV myocardial fibrosis and a reduced strain were revealed. These parameters support the assessment of CV risk and prognosis. They can accurately be measured with CMR within a single examination when normally different techniques are needed.

Stress-Only Adenosine CMR Improves Diagnostic Yield in Stable Symptomatic Patients With Coronary Artery Calcium

ObjectivesThis study assessed whether adenosine stress-only perfusion cardiac magnetic resonance (CMR) following a positive coronary artery calcium (CAC) score improved the diagnostic yield of invasive coronary angiography (CAG) in patients with stable chest pain. The study also established the association between positive CAC scores and stress-induced myocardial ischemia. BackgroundThe diagnostic yield of catheterization among patients with suspected coronary artery disease (CAD) is low. Improved patient selection and diagnostic testing are necessary. The CAC score can minimize unnecessary diagnostic testing, and in low-risk patients, normal CMR results have a high negative predictive value. Less comprehensive protocols may be sufficient to guide further work-up. MethodsA total of 642 consecutive patients (mean age: 63 years; 50% women) with stable chest pain and CAC scores of >0 who were referred for CMR were enrolled. Patients with a perfusion defect were subsequently examined by CAG. Patients were followed up for 1 year. Outcome was obstructive CAD. ResultsObstructive CAD was present in 12% of patients. For CAD diagnosis, the sensitivity of adenosine CMR was 90.9% (95% confidence interval [CI]: 88.7 to 93.1), specificity was 98.7% (95% CI: 97.9 to 99.6), positive predictive value was 92.0% (95% CI: 89.8 to 94.1), and negative predictive value was 98.6% (95% CI: 97.6 to 99.5). A CAC score between 0.1 and 100 without typical angina was associated with obstructive CAD in only 3% of patients. Patients with nonanginal chest pain and a CAC score ≥400 had obstructive CAD (16%). ConclusionsStress-only adenosine CMR had high diagnostic accuracy and served as an efficient gatekeeper to CAG in stable patients with a CAC score >0. Patients with CAC scores between 0.1 and 100 could be deferred from further testing in the absence of clinical features that suggested high risk. However, in patients with CAC score ≥400, functional testing should be indicated, regardless of the type of chest pain.

P5268Prognostic implications of cardiac magnetic resonance in patient with mid range ejection fraction: can we predict worse outcomes?

Abstract Purpose According to current ESC guidelines, mid-range ejection fraction (mrEF) might represent a separate subgroup of patients with distinct underlying characteristics, prognosis and treatment response. Cardiac magnetic resonance (CMR) is the gold standard for measuring volumes, mass and ejection fraction of the heart. We aimed to find long-term prognostic value of various CMR parameters in patients mrEF. Methods 137 patients with mrEF underwent CMR (1.5T) between 2012 and 2018 and were consecutively included. Volumes, mass and ejection fraction were assessed using short axis SSFP images and the Simpson method (using commercially available software). Myocardial fibrosis was determined by late gadolinium enhancement (LGE). Clinical parameters after a median of 762 (230–1315 days) were recorded. Patients with other significant cardiac affection rather than mrEF were excluded (pre-capillary pulmonary hypertension and significant valve disease). The primary endpoint was defined as a combined outcome of all-cause death or heart failure decompensation requiring in-hospital admission. Results Mean age was 63.0±12.4 years. 76.6% were males. Mean left ventricle ejection fraction (LVEF) was 45±2.69%. Main aetiologies were ischemic (46%), idiopathic (32.12%), myocarditis (9.5%), tachycardiomyopathy (6.57%) enolic (2.2%) stress cardiomyopathy (0.7%) and others (2.9%). A combined model for predicting outcomes in patients with mrEF using CMR parameters was obtained. This model was able to predict 32.7% (coefficient of determination, R-squared) of the adverse events (p&lt;0.01). Significant CMR parameters and results are shown on table 1. Combined model for predicting outcomes in patients with mrEF using CMR parameters Variable p value iRVEDV (indexed right ventricular end-diastolic volume) &lt;0.01 RVEF (right ventricle ejection fraction 0.03 iRVESV (indexed right ventricular end-systolic volume) &lt;0.01 Presence of late enhancement (yes/no) 0.09 iLA (indexed left atrial) Volume &lt;0.01 iLV (indexed left ventricle) mass &lt;0.01 Variables and their significance are shown individually. Conclusions In patients with mid-range ejection fraction, RV volumes and ejection fraction, as well as LV mass and LA volume, were significant predictors of worse outcomes in a combined model. If supported by further studies, these findings may help the clinician select the patients with higher risk of complications and in need of a closer follow-up.

Relationship between atrial scar on cardiac magnetic resonance and pulmonary vein reconnection after catheter ablation for paroxysmal atrial fibrillation.

Pulmonary vein (PV) reconnection is frequent in patients showing atrial fibrillation (AF) recurrence after PV isolation (PVI). Its detection with cardiac magnetic resonance (CMR) may help predict outcome and guide redo procedures. We assessed the relationship between scar on CMR and PV reconnection after catheter ablation for paroxysmal AF. Fifty-one patients with paroxysmal AF underwent CMR before PVI using either a conventional single-electrode catheter (N = 28) or a circular multielectrode catheter (N = 23). At 3 months, a second CMR study was performed, followed by a systematic electrophysiological procedure to look for PV reconnection, regardless of AF recurrence. Preablation fibrosis and postablation scar were quantified and mapped from late gadolinium-enhanced CMR. CMR results were compared to the distribution and extent of PV reconnection. CMR and electrophysiological findings were compared between catheter types. Three months after successful PVI, scar gaps were found in 39 (76%) patients, and 78 (39%) veins. Electrical PV reconnection was detected in 45 (88%) patients, and 99 (50%) veins. The extent of PV reconnection related closely to the number of gaps (R = 0.55; P < .001), and to scar burden (R = -0.63; P < .001). However, the agreement was only fair for the localization of PV reconnection (k = 0.37; P < .001), scar gaps particularly lacking sensitivity in areas of pre-existing fibrosis. The circular catheter was associated with shorter procedures (P < .001), more scar (P = .01), less gaps (P = .01), and less reconnected veins (P = .03). PV reconnection is extremely frequent after PVI. CMR scar imaging accurately predicts its extent, but poorly predicts its location. Multielectrode circular catheters induce more complete ablation.

High-Risk Cardiovascular Conditions in Sports-Related Sudden Death: Prevalence in 5,169 Schoolchildren Screened via Cardiac Magnetic Resonance.

Improving preparticipation screening of candidates for sports necessitates establishing the prevalence of high-risk cardiovascular conditions (hr-CVC) that predispose young people to sudden cardiac death (SCD). Our accurate, novel protocol chiefly involved the use of cardiac magnetic resonance (CMR) to estimate this prevalence. Middle and high school students from a general United States population were screened by means of questionnaires, resting electrocardiograms, and CMR to determine the prevalence of 3 types of hr-CVC: electrocardiographic abnormalities, cardiomyopathies, and anomalous coronary artery origin from the opposite sinus with intramural coronary course (ACAOS-IM). We examined the range of normal left ventricular size and function in the main study cohort (schoolchildren 11-14 yr old). We defined diagnostic criteria for hr-CVC and compared the cardiac measurements of these younger participants with those of older children whom we examined (age, 15-18 yr). From 5,169 completed diagnostic studies (mean participant age, 13.06 ± 1.78 yr), CMR results revealed 76 previously undiagnosed cases of hr-CVC (1.47% of the total cohort): 11 of dilated cardiomyopathy (14.5%), 3 of nonobstructive hypertrophic cardiomyopathy (3.9%), 23 ACAOS-IM cases (30.3%; 6 left-ACAOS and 17 right-ACAOS), 4 Wolff-Parkinson-White patterns (5.3%), 34 prolonged QT intervals (44.7%), and 1 Brugada pattern (1.3%). Cardiomyopathies were significantly more prevalent in the older children. Of note, we identified 959 cases (18.5%) of left ventricular noncompaction. If our estimate is accurate, only 1.47% of school-age sports participants will need focused secondary evaluations; the rest can probably be reassured about their cardiac health after one 30-minute screening study.

Cardiac Magnetic Resonance in long term follow-up of Tetralogy of Fallot

Tetralogy of Fallot (TOF) is the most frequent cyanotic congenital heart disease. Pulmonary regurgitation (PR) and right ventricle (RV) enlargement and dysfunction are the most common long-term complications. Cardiac magnetic resonance (CMR) is the gold standard for RV evaluation. To analyze CMR results in the follow-up of TOF patients. All CMR performed between 2007 and 2012 in TOF patients with transannular patch (TAP) repair or infundibular widening, and without pulmonary valve replacement (PVR) were included. Pulmonary regurgitant fraction (PRF), ventricular end-diastolic (EDV) and end-systolic volume (ESV), and ejection fraction (EF) were examined. 122 CMR were performed in 114 patients. Average age at CMR was 15.4±7.4 years. 53.3% of them presented severe PR (> 40%). RVEDV was 157.3 ± 38.6 ml/m2, RVESV was 85.3 ± 27 ml/m2 and RVEF was 46.4 ± 7.1%. RVEDV was > 150 ml/ m2 in 48.4% and > 170 ml/m2 in 32.8% of patients. Patients with TAP showed larger RV volumes compared with those with infundibular widening. RVEDV > 170 ml/m2 showed worse RVEF that those with lower RVEDV (47.9 ± 7% vs 43.2 ± 6.4%, p < 0.01). Almost half of the pa tients showed significant RV enlargement, demonstrating that the indication of CMR is late in their follow-up. TAP was associated with higher RVEDV and RVESV, but no worse RVEF.

Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions

BackgroundDiabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD).MethodsPatients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR.ResultsNinety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88).ConclusionsIn this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease.Trial Registration Name of Registry: Evaluation of cardiac biomarker elevation after percutaneous coronary intervention or coronary artery bypass graft; URL: http://www.controlled-trials.com.ISRCTN09454308

Cardiac MR perfusion imaging: where we are.

To date, several clinical and multicentre studies have demonstrated the accuracy of perfusion cardiac magnetic resonance to detect ischaemia in comparison with quantitative coronary angiography, other noninvasive diagnostic techniques (single photon emission computed tomography; positron-emission tomography), and invasive haemodynamic measurements (fractional flow reserve). Moreover, the favourable safety profile and increasing availability contribute to make perfusion cardiac magnetic resonance one of the modalities of choice for the detection of myocardial ischaemia. Recently, the first evidence of the prognostic value of perfusion cardiac magnetic resonance results has also become available. This review summarises the technical and interpretation key points of perfusion cardiac magnetic resonance scan, the clinical indications, the most recent available literature about its diagnostic performance and prognostic value, and how perfusion cardiac magnetic resonance compares with other noninvasive techniques.

Effect of renal denervation on left ventricular mass and function in patients with resistant hypertension: data from a multi-centre cardiovascular magnetic resonance imaging trial

Sympathetic stimulation induces left ventricular hypertrophy and is associated with increased cardiovascular risk. Catheter-based renal denervation (RDN) has been shown to reduce sympathetic outflow and blood pressure (BP). The present multi-centre study aimed to investigate the effect of RDN on anatomic and functional myocardial parameters, assessed by cardiac magnetic resonance (CMR), in patients with resistant hypertension. Cardiac magnetic resonance was performed in 72 patients (mean age 66 ± 10 years) with resistant hypertension (55 patients underwent RDN, 17 served as controls) at baseline and after 6 months. Clinical data and CMR results were analysed blindly. Renal denervation significantly reduced systolic and diastolic BP by 22/8 mm Hg and left ventricular mass index (LVMI) by 7.1% (46.3 ± 13.6 g/m(1.7) vs. 43.0 ± 12.6 g/m(1.7), P < 0.001) without changes in the control group (41.9 ± 10.8 g/m(1.7) vs. 42.0 ± 9.7 g/m(1.7), P = 0.653). Ejection fraction (LVEF) in patients with impaired LVEF at baseline (<50%) significantly increased after RDN (43% vs. 50%, P < 0.001). Left ventricular circumferential strain as a surrogate of diastolic function in the subgroup of patients with reduced strain at baseline increased by 21% only in the RDN group (-14.8 vs. -17.9; P = 0.001) and not in control patients (-15.5 vs. -16.4, P = 0.508). Catheter-based RDN significantly reduced BP and LVMI and improved EF and circumferential strain in patients with resistant hypertension, occurring partly BP independently.

Cardiac magnetic resonance imaging and echocardiography in pediatric pulmonary arterial hypertension.

Editor: We read with great interest the article “Magnetic Resonance Imaging of the Right Ventricle in Pediatric Pulmonary Arterial Hypertension” by Blalock et al.1 They present highly valuable cardiac magnetic resonance (CMR) data on children with idiopathic pulmonary arterial hypertension (IPAH) without a secondary cause of PAH, such as congenital heart disease (CHD). It has recently been shown that in patients with chronic pressure overload the resulting right ventricular (RV) myocardial damage can be demonstrated by an impaired RV long-axis function.2 Blalock and colleagues found an impaired RV function in children with IPAH. They describe an increased indexed RV end-diastolic volume (RVEDVi) and a reduced RV ejection fraction in comparison to healthy controls. For the convenience of the audience of Pulmonary Circulation, we want to add that their data are in agreement with results obtained in patients with PAH secondary to CHD (PAH-CHD).3,4 However, we find a higher RVEDVi in PAH-CHD patients, which might be related to their multiple surgical procedures. It has been shown that echocardiographic measures of systolic RV function, such as tricuspid annular peak systolic velocity and tricuspid annular plane systolic excursion, correlate with CMR data on patients with PAH-CHD.3,4 Considering that about half of PAH patients in childhood have underlying CHD,5 the CMR results of Blalock and colleagues and the respective echocardiographic results of Kassem et al.6 in patients with IPAH add up to our data in PAH-CHD patients and together provide a compact image of RV function in pediatric PAH patients. We want to thank the authors for addressing the need to investigate RV function parameters in children with IPAH. In the future, with increasing data in pediatric PAH patients, echocardiography, in addition to the gold standard method, CMR, may become the technique of choice for routine assessment of systolic RV function in the follow-up of patients with PAH.

Incremental Value of Cardiac Magnetic Resonance Imaging in Arrhythmic Risk Stratification of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy–Associated Desmosomal Mutation Carriers

The aim of this study was to identify the incremental value and optimal role of cardiac magnetic resonance (CMR) imaging in arrhythmic risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C)-associated desmosomal mutation carriers without histories of sustained ventricular arrhythmia. Risk stratification of ARVD/C mutation carriers is challenging. Sixty-nine patients (mean age 27.0 ± 15.3 years, 42% men) harboring ARVD/C-associated pathogenic mutations (83% plakophilin 2) without prior sustained ventricular arrhythmias were included. Electrocardiographic and 24-h Holter monitoring findings closest to presentation were analyzed for electrical abnormalities per revised task force criteria. CMR studies were done to identify abnormal cardiac structure and function according to the revised task force criteria. Overall, 42 patients (61%) presented with electrical abnormalities on the basis of electrocardiography and Holter monitoring, of whom 20 (48%) had abnormal results on CMR. Only 1 of 27 patients (4%) without electrical abnormalities at initial evaluation had abnormal CMR results. Over a mean follow-up period of 5.8 ± 4.4 years, 11 patients (16%) experienced sustained ventricular arrhythmias, exclusively in patients with both electrical abnormalities (electrocardiography and/or Holter monitoring) and abnormal CMR results. These results suggest that electrical abnormalities on electrocardiography and Holter monitoring precede detectable structural abnormalities in ARVD/C mutation carriers. Therefore, evaluation of cardiac structure and function using CMR is probably not necessary in the absence of baseline electrical abnormalities. Among ARVD/C mutation carriers, the presence of both electrical and CMR abnormalities identifies patients at high risk for events and thus patients who might benefit from prophylactic implantable cardioverter-defibrillator placement.

Renal denervation reduces left ventricular mass in patients with resistant hypertension - results from a multicenter CMR-study

Background Left ventricular (LV) hypertrophy is a common finding in patients with resistant hypertension and is associated with increased sympathetic activity and high cardiovascular risk. Catheter-based renal denervation (RD) has been shown to reduce blood pressure (BP) and sympathetic tone. The present study aimed to investigate the effect of RD on left ventricular mass, assessed by cardiac magnetic resonance (CMR), in patients with resistant hypertension compared to a control group of medical treated patients. Methods CMR was performed in 37 patients at baseline and 6 months after RD in a multicenter setting with 9 subjects serving as controls. Resistant hypertension was defined as office systolic BP >160 mmHg and >150 mmHg for patients with type 2 diabetes. Clinical data and CMR results were analyzed blinded at both times. Data were analyzed using the paired or unpaired t-test. All continuous parameters are given as mean + one standard deviation (SD). For all tests, p<0.05 was considered statistically significant. All tests were two-sided. Results Patients were middle aged (63 ± 11 years vs. 70 ± 8 years in the control group), had poorly controlled BP and heavily medicated. RD significantly reduced systolic BP and LV mass indexed to heigt1.7 by 7.7 % (50.83 ± 11.3 g/m1.7 at baseline vs. 46.91 ± 11.5 g/m1.7 after 6 months, p<0.001, N=27). In contrast, LV mass did not change in the control group (42.7 ± 9.8 g/m1.7 at baseline vs. 43.3 ± 9.4 g/m1.7 after 6 months, p = 0.516). Ejection fraction remained constant in the RD group (55.8 ±10.6% vs. 58.7±9.5% at 6 months; p=0.109) as well as in the control group (58.5 ± 8.6% vs. 58.7 ± 10.0%, p=0.873). No significant changes between baseline and 6 months were evident for LV end-systolic volume and LV end-diastolic volume, neither in the RD group (ESV: 83.0 ± 39.0 ml vs. 77.2 ± 35.2 ml; p=0.189 and EDV: 182.0 ± 51.8 ml vs. 180.9 ± 49.2; p=0.796), nor in the controls (ESV: 69.6 ± 39.0 ml vs. 68.4 ± 33.4 ml, P=0.746 and EDV: 160.2 ± 50.2 vs. 158.6 ± 37.3 ml, p=0.812). Conclusions Catheter-based renal denervation significantly reduced left ventricular mass in patients with resistant hypertension, as diagnosed by CMR. This might have important prognostic implications in patients with resistant hypertension and high cardiovascular risk. Funding Medtronic.

T1 Mapping in Cardiomyopathy at Cardiac MR: Comparison with Endomyocardial Biopsy

To determine the utility of cardiac magnetic resonance (MR) T1 mapping for quantification of diffuse myocardial fibrosis compared with the standard of endomyocardial biopsy. This HIPAA-compliant study was approved by the institutional review board. Cardiomyopathy patients were retrospectively identified who had undergone endomyocardial biopsy and cardiac MR at one institution during a 5-year period. Forty-seven patients (53% male; mean age, 46.8 years) had undergone diagnostic cardiac MR and endomyocardial biopsy. Thirteen healthy volunteers (54% male; mean age, 38.1 years) underwent cardiac MR as a reference. Myocardial T1 mapping was performed 10.7 minutes ± 2.7 (standard deviation) after bolus injection of 0.2 mmol/kg gadolinium chelate by using an inversion-recovery Look-Locker sequence on a 1.5-T MR imager. Late gadolinium enhancement was assessed by using gradient-echo inversion-recovery sequences. Cardiac MR results were the consensus of two radiologists who were blinded to histopathologic findings. Endomyocardial biopsy fibrosis was quantitatively measured by using automated image analysis software with digital images of specimens stained with Masson trichrome. Histopathologic findings were reported by two pathologists blinded to cardiac MR findings. Statistical analyses included Mann-Whitney U test, analysis of variance, and linear regression. Median myocardial fibrosis was 8.5% (interquartile range, 5.7-14.4). T1 times were greater in control subjects than in patients without and in patients with evident late gadolinium enhancement (466 msec ± 14, 406 msec ± 59, and 303 msec ± 53, respectively; P < .001). T1 time and histologic fibrosis were inversely correlated (r = -0.57; 95% confidence interval: -0.74, -0.34; P < .0001). The area under the curve for myocardial T1 time to detect fibrosis of greater than 5% was 0.84 at a cutoff of 383 msec. Cardiac MR with T1 mapping can provide noninvasive evidence of diffuse myocardial fibrosis in patients referred for evaluation of cardiomyopathy.

Diagnostic Performance of CMR Imaging Compared With EMB in Patients With Suspected Myocarditis

The goal of this study was to assess the diagnostic performance of cardiac magnetic resonance (CMR) compared with endomyocardial biopsy in patients with suspected acute myocarditis (AMC) and chronic myocarditis (CMC). Several studies have reported an encouraging diagnostic performance of CMR in myocarditis. However, the comparison of CMR with clinical data only and the use of preselected patient populations are important limitations of the majority of these reports. One hundred thirty-two consecutive patients with suspected AMC (defined by symptoms ≤ 14 days; n = 70) and CMC (defined by symptoms >14 days; n = 62) were included. Patients underwent cardiac catheterization with left ventricular endomyocardial biopsy and CMR, including T(2)-weighted imaging for assessment of edema, T(1)-weighted imaging before and after contrast administration for evaluation of hyperemia, and assessment of late gadolinium enhancement. CMR results were considered to be consistent with the diagnosis of myocarditis if 2 of 3 CMR techniques were positive. Within the total population, myocarditis was the most common diagnosis on endomyocardial biopsy analysis (62.9%). Viral genomes were detected in 30.3% (40 of 132) of patients within the total patient population and significantly more often in patients with AMC than CMC (40.0% vs. 19.4%; p = 0.013). For the overall cohort of patients with either suspected AMC or CMC, the diagnostic sensitivity, specificity, and accuracy of CMR were 76%, 54%, and 68%, respectively. The best diagnostic performance was observed in patients with suspected AMC (sensitivity, 81%; specificity, 71%; and accuracy, 79%). In contrast, diagnostic performance of CMR in suspected CMC was found to be unsatisfactory (sensitivity, 63%; specificity, 40%; and accuracy, 52%). The results of this study underline the usefulness of CMR in patients with suspected AMC. In contrast, the diagnostic performance of CMR in patients with suspected CMC might not be sufficient to guide clinical management.

3D color-Doppler echocardiography and chronic aortic regurgitation: A novel approach for severity assessment

Background3D echocardiography provides a complete evaluation of the aortic valve and adjacent structures and it improves the assessment of this cardiac region. Three-dimensional color-Doppler echocardiography (3DCDE) evaluation might improve the measurements of the functional regurgitant orifice in patients with Chronic Aortic Regurgitation (CAR). ObjectivesOur aim was to compare the accuracy of current echo-Doppler methods and 3DCDE for the assessment of CAR severity. The reference method used in this work was the CAR severity determined by means of cardiac magnetic resonance (CMR) MethodsThirty-two consecutive patients with an established diagnosis of CAR recruited in our institution comprised our study group. CAR severity was determined by conventional Echo-Doppler methods and by 3DCDE and their results were compared with those obtained by means of CMR. ResultsMean age was 63.0±13.5years. Twenty-two patients (68.8%) were men. Compared with the traditional echo-Doppler methods, 3DCDE evaluation had the best linear association with CMR results (3D vena contracta cross sectional area method: r=0.88; r square=0.77; p<0.001. 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method: r=0.87; r square=0.75; p<0.001). The ROC analysis showed an excellent area under curve for detection of severe CAR (3D vena contracta cross sectional area method=0.97; 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method=0.98). Inter- and intra-observer variability for the 3DCDE evaluation was good (ICC=0.89 and ICC=0.91 for inter and intra observer variability respectively). Conclusions3DCDE is an accurate and highly reproducible diagnostic tool for estimating CAR severity. Compared with the traditional echo-Doppler methods, 3DCDE has the best agreement with the CMR determined CAR severity. Thus, 3DCDE is a diagnostic method that may improve the therapeutic management of patients with CAR.

Combining cardiac magnetic resonance and computed tomography coronary calcium scoring: added value for the assessment of morphological coronary disease?

To investigate prospectively, in patients with suspicion of coronary artery disease (CAD), the added value of coronary calcium scoring (CS) as adjunct to cardiac magnetic resonance (CMR) for the diagnosis of morphological coronary stenosis in comparison to catheter angiography (CA). Sixty consecutive patients (8 women; 64±10years) referred to CA underwent CMR (1.5 T) including perfusion and late gadolinium-enhancement imaging as well as CS with computed tomography. Diagnostic performance was evaluated for CMR and CS separately, and for both methods combined, with CA as reference standard. Best CS threshold combined with a specificity >90% to predict significant stenosis in patients without abnormalities on CMR was determined from receiver operator characteristics (ROC) analysis. Abnormal CMR results were considered to indicate significant stenosis regardless of CS; CS above threshold reclassified patients to have CAD regardless of CMR. CA identified 104/960 (11%) coronary segments with coronary artery stenosis >50% in 36/60 (60%) patients. ROC revealed an area-under-the-curve of 0.83 (95%CI: 0.68-0.99) with the best CS threshold of 495 Agatston score (sensitivity 50%). CMR depicted 128/960 (13%) myocardial segments with abnormalities in 31/60 (52%) patients. Sensitivity, specificity, negative (NPV) and positive predictive value (PPV) of CMR were 78, 88, 72 and 90%. When adding CS to CMR, sensitivity and NPV increased to 89 and 83%, while specificity and PPV slightly decreased to 83 and 89%. Accuracy of the combined approach (87%) was significantly (P<0.05) higher than that of CMR (82%) alone. Adding CS to CMR improves the accuracy for the detection of morphological CAD.

Influence of small caliber coronary arteries on the diagnostic accuracy of adenosine stress cardiac magnetic resonance imaging

Background and aimsPositive predictive value (PPV) of adenosine stress cardiac magnetic resonance (CMR) for coronary artery disease (CAD) is unsatisfactory. We investigated the impact of coronary caliber variability on this limitation in CMR performance.Methods and results206 consecutive patients with myocardial ischemia during CMR and subsequent coronary angiography (CA) were studied. Patients were examined in a 1.5-T scanner. After adenosine infusion, myocardial first-pass sequence using gadolinium-based contrast agent was performed and compared with rest perfusion. CAD was invasively confirmed in 165 [true positive (TP); PPV, 80.1%] and ruled out in 41 patients [false positive (FP)]. TP and FP were comparable for pre-test risk and CMR findings. We found a significant association between FP CMR and the presence of a small caliber coronary vessel (proximal diameter < one standard deviation below the mean) supplying the area of ischemia (chi-square 42.6, p < 0.0001). A small caliber artery ipsilateral to the ischemic region was a predictive parameter for FP versus TP discrimination (ROC area, 0.84 ± 0.04 vs. 0.59 ± 0.05; p < 0.0001). Further increment in diagnostic accuracy was achieved by including proximal ipsilateral/contralateral coronary diameter ratios (ROC area, 0.90 ± 0.03; p < 0.03).ConclusionsSmall caliber coronary arteries found as normal variations in right-dominant or left-dominant circulation may account for hypoperfusion in the absence of coronary stenosis and thus may cause FP adenosine stress CMR results. Non-invasive assessment of proximal coronary diameters in the vessel supplying the area of ischemia could reduce FP rates, raise the diagnostic accuracy of CMR for CAD and minimize subsequent superfluous CA.