Cardiovascular Magnetic Resonance Study Research Articles

Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation.

Endomyocardial biopsy (EMB) is the gold standard method for surveillance of acute cardiac allograft rejection (ACAR) despite its invasive nature. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization allows detection of myocarditis. The feasibility of CMR-based surveillance for ACAR-induced myocarditis in the first year after heart transplantation is currently undescribed. CMR-based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between CMR- and EMB-based ACAR and to determine CMR cutoff values between rejection grades. A prospective randomized noninferiority pilot study was then undertaken in adult orthotopic heart transplant recipients who were randomized at 4 weeks after orthotopic heart transplantation to either CMR- or EMB-based rejection surveillance. Clinical end points were assessed at 52 weeks. Four hundred one CMR studies and 354 EMB procedures were performed in 106 participants. Forty heart transplant recipients were randomized. CMR-based multiparametric assessment was highly reproducible and reliable at detecting ACAR (area under the curve, 0.92; sensitivity, 93%; specificity, 92%; negative predictive value, 99%) with greater specificity and negative predictive value than either T1 or T2 parametric CMR mapping alone. High-grade rejection occurred in similar numbers of patients in each randomized group (CMR, n=7; EMB, n=8; P=0.74). Despite similarities in immunosuppression requirements, kidney function, and mortality between groups, the rates of hospitalization (9 of 20 [45%] versus 18 of 20 [90%]; odds ratio, 0.091; P=0.006) and infection (7 of 20 [35%] versus 14 of 20 [70%]; odds ratio, 0.192; P=0,019) were lower in the CMR group. On 15 occasions (6%), patients who were randomized to the CMR arm underwent EMB for clarification or logistic reasons, representing a 94% reduction in the requirement for EMB-based surveillance. A noninvasive CMR-based surveillance strategy for ACAR in the first year after orthotopic heart transplantation is feasible compared with EMB-based surveillance. HREC/13/SVH/66 and HREC/17/SVH/80. ACTRN12618000672257.

Validation of time-resolved, automated peak trans-mitral velocity tracking: Two center four-dimensional flow cardiovascular magnetic resonance study

ObjectiveWe aim to validate four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) peak velocity tracking methods for measuring the peak velocity of mitral inflow against Doppler echocardiography. MethodFifty patients were recruited who had 4D flow CMR and Doppler Echocardiography. After transvalvular flow segmentation using established valve tracking methods, peak velocity was automatically derived using three-dimensional streamlines of transvalvular flow. In addition, a static-planar method was used at the tip of mitral valve to mimic Doppler technique. ResultsPeak E-wave mitral inflow velocity was comparable between TTE and the novel 4D flow automated dynamic method (0.9 ± 0.5 vs 0.94 ± 0.6 m/s; p = 0.29) however there was a statistically significant difference when compared with the static planar method (0.85 ± 0.5 m/s; p = 0.01). Median A-wave peak velocity was also comparable across TTE and the automated dynamic streamline (0.77 ± 0.4 vs 0.76 ± 0.4 m/s; p = 0.77). A significant difference was seen with the static planar method (0.68 ± 0.5 m/s; p = 0.04). E/A ratio was comparable between TTE and both the automated dynamic and static planar method (1.1 ± 0.7 vs 1.15 ± 0.5 m/s; p = 0.74 and 1.15 ± 0.5 m/s; p = 0.5 respectively). Both novel 4D flow methods showed good correlation with TTE for E-wave (dynamic method; r = 0.70; P < 0.001 and static-planar method; r = 0.67; P < 0.001) and A-wave velocity measurements (dynamic method; r = 0.83; P < 0.001 and static method; r = 0.71; P < 0.001). The automated dynamic method demonstrated excellent intra/inter-observer reproducibility for all parameters. ConclusionAutomated dynamic peak velocity tracing method using 4D flow CMR is comparable to Doppler echocardiography for mitral inflow assessment and has excellent reproducibility for clinical use.

Therapeutic value of tafamidis in patients with wild-type transthyretin amyloidosis (ATTRwt) with cardiomyopathy based on cardiovascular magnetic resonance (CMR) imaging

ObjectivesThe purpose of this study was to carefully analyse the therapeutic benefit of tafamidis in patients with wild-type transthyretin amyloidosis (ATTRwt) and cardiomyopathy (ATTRwt-CM) after one year of therapy based on serial multi-parametric cardiovascular magnetic resonance (CMR) imaging.BackgroundNon-sponsored data based on multi-parametric CMR regarding the effect of tafamidis on the cardiac phenotype of patients with ATTRwt-CM are not available so far.MethodsThe present study comprised N = 40 patients with ATTRwt-CM who underwent two serial multi-parametric CMR studies within a follow-up period of 12 ± 3 months. Baseline (BL) clinical parameters, serum biomarkers and CMR findings were compared to follow-up (FU) values in patients treated “with” tafamidis 61 mg daily (n = 20, group A) and those “without” tafamidis therapy (n = 20, group B). CMR studies were performed on a 1.5-T system and comprised cine-imaging, pre- and post-contrast T1-mapping and additional calculation of extracellular volume fraction (ECV) values.ResultsWhile left ventricular ejection fraction (LV-EF), left ventricular mass index (LVMi), left ventricular wall thickness (LVWT), native T1- and ECV values remained unchanged in the tafamidis group A, a slight reduction in LV-EF (p = 0.003) as well as a subtle increase in LVMi (p = 0.034), in LVWT (p = 0.001), in native T1- (p = 0.038) and ECV-values (p = 0.017) were observed in the untreated group B. Serum NT-proBNP levels showed an overall increase in both groups, however, with the untreated group B showing a relatively higher increase compared to the treated group A. Assessment of NYHA class did not result in significant intra-group differences when BL were compared with FU, but a trend to improvement in the treated group A compared to a worsening trend in the untreated group B (∆p = 0.005).ConclusionAs expected, tafamidis does not improve cardiac phenotype in patients with ATTRwt-CM after one year of therapy. However, tafamidis seems to slow down cardiac disease progression in patients with ATTRwt-CM compared to those without tafamidis therapy based on multi-parametric CMR data already after one year of therapy.

Pericardial adiposity is independently linked to adverse cardiovascular phenotypes: a CMR study of 42 598 UK Biobank participants.

AimsWe evaluated independent associations of cardiovascular magnetic resonance (CMR)-measured pericardial adipose tissue (PAT) with cardiovascular structure and function and considered underlying mechanism in 42 598 UK Biobank participants.Methods and resultsWe extracted PAT and selected CMR metrics using automated pipelines. We estimated associations of PAT with each CMR metric using linear regression adjusting for age, sex, ethnicity, deprivation, smoking, exercise, processed food intake, body mass index, diabetes, hypertension, height cholesterol, waist-to-hip ratio, impedance fat measures, and magnetic resonance imaging abdominal visceral adiposity measures. Higher PAT was independently associated with unhealthy left ventricular (LV) structure (greater wall thickness, higher LV mass, more concentric pattern of LV hypertrophy), poorer LV function (lower LV global function index, lower LV stroke volume), lower left atrial ejection fraction, and lower aortic distensibility. We used multiple mediation analysis to examine the potential mediating effect of cardiometabolic diseases and blood biomarkers (lipid profile, glycaemic control, inflammation) in the PAT-CMR relationships. Higher PAT was associated with cardiometabolic disease (hypertension, diabetes, high cholesterol), adverse serum lipids, poorer glycaemic control, and greater systemic inflammation. We identified potential mediation pathways via hypertension, adverse lipids, and inflammation markers, which overall only partially explained the PAT-CMR relationships.ConclusionWe demonstrate association of PAT with unhealthy cardiovascular structure and function, independent of baseline comorbidities, vascular risk factors, inflammatory markers, and multiple non-invasive and imaging measures of obesity. Our findings support an independent role of PAT in adversely impacting cardiovascular health and highlight CMR-measured PAT as a potential novel imaging biomarker of cardiovascular risk.

Noncontrast T1ρ dispersion imaging is sensitive to diffuse fibrosis: A cardiovascular magnetic resonance study at 3T in hypertrophic cardiomyopathy

PurposeTo determine the sensitivity of a noncontrast T1 dispersion cardiovascular magnetic resonance technique for detecting diffuse fibrosis in hypertrophic cardiomyopathy (HCM). MethodsThirty-two adult HCM patients and ten age- and gender-matched healthy volunteers were prospectively included in this study. Patients and controls underwent cine, T1ρ-mapping, and pre- and post-contrast T1-mapping imaging using a 3-T magnetic resonance system. Myocardial extracellular volume fraction (ECV) maps were obtained using pre- and post-contrast T1 maps to determine reference values for diffuse fibrosis. Myocardial T1ρ and T1ρ dispersion maps called myocardial fibrosis index (mFI) maps provided 570 myocardial segments for Pearson or Spearman correlation analysis. The left ventricle myocardia of the HCM patients were divided into 16 segments that were further classified as either normal-thickness myocardium (<15 mm) (HCM-N) or hypertrophic myocardium (≥15 mm) (HCM-H). ResultsECV and mFI values increased progressively on a per-segment basis from healthy controls to the HCM-N group and then to the HCM-H group (ECV: 27.4 ± 2.8% vs. 31.1 ± 4.2% vs. 37.6 ± 6.9%, respectively [P < 0.0001]; mFI: 6.1 ± 0.9 ms vs. 8 ± 1.9 ms vs. 11 ± 3.3 ms, respectively [P < 0.0001]). There was a strong positive correlation between the segmented ECV and the mFI (r = 0.878). The mFI was equally or significantly better than the ECV for differentiating fibrosis content in HCM-N and HCM-H according to their receiver operating characteristic curves. ConclusionA T1ρ dispersion imaging mFI can sensitively detect diffuse myocardial fibrosis in HCM, even in HCM-N.

Serial Cardiovascular Magnetic Resonance Studies Prior to and After mRNA-Based COVID-19 Booster Vaccination to Assess Booster-Associated Cardiac Effects.

BackgroundmRNA-based COVID-19 vaccination is associated with rare but sometimes serious cases of acute peri-/myocarditis. It is still not well known whether a 3rd booster-vaccination is also associated with functional and/or structural changes regarding cardiac status. The aim of this study was to assess the possible occurrence of peri-/myocarditis in healthy volunteers and to analyze subclinical changes in functional and/or structural cardiac parameters following a mRNA-based booster-vaccination.Methods and ResultsHealthy volunteers aged 18–50 years (n = 41; m = 23, f = 18) were enrolled for a CMR-based serial screening before and after 3rd booster-vaccination at a single center in Germany. Each study visit comprised a multi-parametric CMR scan, blood analyses with cardiac markers, markers of inflammation and SARS-CoV-2-IgG antibody titers, resting ECGs and a questionnaire regarding clinical symptoms. CMR examinations were performed before (median 3 days) and after (median 6 days) 3rd booster-vaccination. There was no significant change in cardiac parameters, CRP or D-dimer after vaccination, but a significant rise in the SARS-CoV-2-IgG titer (p < 0.001), with a significantly higher increase in females compared to males (p = 0.044). No changes regarding CMR parameters including global native T1- and T2-mapping values of the myocardium were observed. A single case of a vaccination-associated mild pericardial inflammation was detected by T2-weighted CMR images.ConclusionThere were no functional or structural changes in the myocardium after booster-vaccination in our cohort of 41 healthy subjects. However, subclinical pericarditis was observed in one case and could only be depicted by multiparametric CMR.

Serial Assessment of Right Ventricular Deformation in Patients With Hypoplastic Left Heart Syndrome: A Cardiovascular Magnetic Resonance Feature Tracking Study.

BackgroundAs right ventricular dysfunction is a major cause of adverse outcome in patients with hypoplastic left heart syndrome, the aim was to assess right ventricular function and deformation after Fontan completion by performing 2‐dimensional cardiovascular magnetic resonance feature tracking in serial cardiovascular magnetic resonance studies.Methods and ResultsCardiovascular magnetic resonance examinations of 108 patients with hypoplastic left heart syndrome (female: 31) were analyzed. Short‐axis cine images were used for right ventricular volumetry. Two‐dimensional cardiovascular magnetic resonance feature tracking was performed using long‐axis and short‐axis cine images to measure myocardial global longitudinal, circumferential, and radial strain. All patients had at least 2 cardiovascular magnetic resonance examinations after Fontan completion and 41 patients had 3 examinations. Global strain values and right ventricular ejection fraction decreased from the first to the third examination with a significant decline in global longitudinal strain from the first examination to the second examination (median, first, and third quartile: −18.8%, [−20.5;−16.5] versus −16.9%, [−19.3;−14.7]) and from the first to the third examination in 41 patients (−18.6%, [−20.9;−15.7] versus −15.8%, [−18.7;−12.6]; P‐values <0.004). Right ventricular ejection fraction decreased significantly from the first to the third examination (55.4%, [49.8;59.3] versus 50.2%, [45.0;55.9]; P<0.002) and from the second to the third examination (53.8%, [47.2;58.7] versus 50.2%, [45.0;55.9]; P<0.0002).ConclusionsSerial assessment of cardiovascular magnetic resonance studies in patients with hypoplastic left heart syndrome after Fontan completion demonstrates a significant reduction in global strain values and right ventricular ejection fraction at follow‐up. The significant reduction in global longitudinal strain between the first 2 examinations with non‐significant changes in right ventricular ejection fraction suggest that global longitudinal strain measured by 2‐dimensional cardiovascular magnetic resonance feature tracking might be a superior technique for the detection of changes in myocardial function.

Quantitative assessment of left ventricular myocardial involvement in patients with connective tissue disease: a 3.0T contrast-enhanced cardiovascular magnetic resonance study

The aim of this study was to evaluate left ventricular (LV) myocardial involvement in connective tissue disease (CTD) patients using multiparemetric imaging derived from cardiovascular magnetic resonance (CMR). CMR was performed on 146 CTD patients (comprising of 74 with idiopathic inflammatory myopathy (IIM) and 72 with non-IIM) and 72 healthy controls and included measures of LV global strains [including peak strain (PS), peak systolic (PSSR) and diastolic strain rate (PDSR)], myocardial perfusion [including upslope, max signal intensity (MaxSI), and time to maximum signal intensity (TTM)], and late gadolinium enhancement (LGE) parameters. Univariable and multivariable linear regression analyses were performed to determine the association between LV deformation and microvascular perfusion, as well as LGE. Our results indicated that CTD patients had decreased global longitudinal PS (GLPS), PSSR, PDSR, and myocardial perfusion (all p < 0.017) compared with normal controls. Non-IIM patients exhibited lower LV global strain and longer TTM than IIM patients. The presence of LGE was independently associated with global radial PS (GRPS: β = − 0.165, p = 0.011) and global circumferential PS (GCPS: β = − 0.122, p = 0.022). TTM was independently correlated with GLPS (β = − 0.156, p = 0.027). GLPS was the best indicator for differentiating CTD patients from normal controls (area under curve of 0.78). This study indicated that CTD patients showed impaired LV global myocardial deformation and microvascular perfusion, and presence of LGE. Cardiac involvement might be more severe in non-IIM patients than in IIM patients. Impaired microvascular perfusion and the presence of LGE were independently associated with LV global deformation.

Association of aortic distensibility and left ventricular function in patients with stenotic bicuspid aortic valve and preserved ejection fraction: a CMR study.

To determine the relationship between aortic distensibility and left ventricular (LV) remodeling, myocardial strain and blood biomarkers in patients with stenotic bicuspid aortic valve (BAV) and preserved ejection fraction (EF) by cardiovascular magnetic resonance (CMR). 43 stenotic BAV patients were prospectively selected for 3.0T CMR. Patients were divided into LV remodeling group (LV mass/volume ≥ 1.15, n = 21) and non-remodeling group (LV mass/volume < 1.15, n = 22). Clinical characteristics, biochemical data including cardiac troponin T(cTNT), N-terminal pro-B type natriuretic peptide (NT-proBNP) and creatine kinase isoenzyme (CK-MB) were noted. Distensibility of middle ascending aorta (mid-AA) and proximal descending aorta, LV structural and functional parameters, global and regional myocardial strain were measured. Compared to non-remodeling group, LV remodeling group had significantly decreased LV global strain (radial: 26.04 ± 8.70% vs. 32.92 ± 7.81%, P = 0.009; circumferential: - 17.20 ± 3.38% vs. - 19.65 ± 2.34%, P = 0.008; longitudinal: - 9.13 ± 2.34% vs. - 11.63 ± 1.99%, P < 0.001) and decreased mid-AA distensibility (1.22 ± 0.24 10-3mm/Hg vs 1.60 ± 0.41 10-3mm/Hg, P = 0.001). In addition, mid-AA distensibility was independently associated with LV remodeling (β = - 0.282, P = 0.003), and it was also significantly correlated with LV global strain (radial: r = 0.392, P = 0.009; circumferential: r = - 0.348, P = 0.022; longitudinal: r = - 0.333, P = 0.029), cTNT (r = - 0.333, P = 0.029) and NT-proBNP (r = - 0.440, P = 0.003). In this cohort with stenotic BAV and preserved EF, mid-AA distensibility is found significantly associated with LV remolding, which encouraging to better understand mechanism of ventricular vascular coupling.

Cardiac remodeling and subclinical left ventricular dysfunction in adults with uncomplicated obesity: a cardiovascular magnetic resonance study.

Obesity often exists alongside comorbidities and increases the risk of heart failure and cardiovascular mortality. However, the specific effects of obesity on cardiac structure and function have not been clarified. This study set out to evaluate left ventricular (LV) geometric and functional changes using cardiovascular magnetic resonance imaging (CMR) in adults with uncomplicated obesity. Forty-eight patients with uncomplicated obesity [body mass index (BMI) mean ± SD: 29.8±2.1 kg/m2] and 25 healthy controls were included in this study. CMR was used to assess LV geometry, global systolic function, and strains, and to quantify epicardial adipose tissue (EAT). Body composition was measured by dual X-ray absorptiometry. Compared with healthy controls, patients with obesity had increased LV size, mass, and myocardial thickness, and impaired myocardial contractility, with lower global radial, circumferential, and longitudinal peak strains (PS), and circumferential and longitudinal peak diastolic strain rates (PDSR; all P<0.05). Multivariable linear regression showed that BMI was independently associated with LV maximum myocardial thickness (LVMMT) (β=0.197, P=0.016). Visceral adipose tissue (VAT) was independently associated with LV global longitudinal PS (β=-2.684, P=0.001), and both longitudinal (β=-0.192, P=0.002) and circumferential (β=-0.165, P=0.014) PDSR. Homeostasis model assessment of insulin resistance (HOMA-IR) was mildly correlated with BMI (r=0.327) and body fat percentage (BF%) (r=0.295) in patients with obesity (all P<0.05). HOMA-IR was independently associated with LV global circumferential PS (β=-0.276, P=0.04) and PDSR (β=-0.036, P=0.026). Extensive LV geometric remodeling and marked changes in cardiac strains were observed in adults with obesity. Tissue tracking with CMR can reveal subclinical impaired ventricular function with preserved LV ejection fraction in such patients. BMI was independently related to LV remodeling in obesity. HOMA-IR and VAT are potentially superior to BMI as predictors of subclinical dysfunction, assessed by strain, in obesity. This study has been registered with the Chinese Clinical Trial Registry (ID: ChiCTR1900026476; Effect of lifestyle intervention on metabolism of obese patients based on smart phone software).

Left and Right Ventricular Morphology, Function and Myocardial Deformation in Children with Left Ventricular Non-Compaction Cardiomyopathy: A Case-Control Cardiovascular Magnetic Resonance Study.

Background: Left ventricular non-compaction (LVNC) is a rare cardiomyopathy typically involving the left ventricle (LV); however, the right ventricle (RV) can also be affected. This case-control study aimed to assess the morphology and function of LV and RV in children with LVNC. Methods: Sixteen children (13 ± 3 years, six girls) with LVNC were compared with 16 sex- and age-matched controls. LV and RV morphology and function were evaluated in cardiovascular magnetic resonance (CMR) studies. Additionally, LV and RV global radial (GRS), circumferential (GCS), and longitudinal strain (GLS) were assessed using tissue-tracking analysis. Results: Patients with LVNC did not differ from the healthy controls in terms of age, height, weight, and body surface area (BSA). In total, 4/16 subjects with LVNC had mid-wall late gadolinium enhancement (LGE). Compared to the control group, patients with LVNC had higher end-diastolic volume (EDV) indexed for body surface area (BSA), lower ejection fraction (EF), and lower LV strain parameters (all p < 0.05). Children with LVNC also presented with thicker RV apical trabeculation, whereas there were no differences in RV EF and EDV/BSA between the groups. Nevertheless, children with LVNC had impaired RV GRS and GCS (both p < 0.05). Conclusions: LVNC in pediatric patients is associated with LV enlargement and impaired LV systolic function. Additionally, children with LVNC have increased RV trabeculations and subclinical impairment of RV myocardial deformation.

Left atrial adaptation in ischemic heart disease: insights from a cardiovascular magnetic resonance study.

Left atrium (LA) plays a key role in the overall cardiac performance. However, it remains unclear how LA adapts, in terms of function and volumes, to left ventricular dysfunction in the acute and post-acute phases of myocardial infarction. LA volumes and function were evaluated in patients in the acute phase of ST-segment elevation myocardial infarction (acute-STEMI group) and in the post-acute phase after STEMI (post-acute STEMI group). Ten age and sex-matched healthy controls served as control group. In all subjects LA was assessed by a compressed-sensing cine pulse sequence and by a 3D non-model-based reconstruction. LV infarct size and microvascular obstruction were determined on late-gadolinium-enhancement data and LV myocardial oedema and myocardial haemorrhage were measured on T2-mapping data. Indexed LA maximum and minimum volumes did not differ between the acute (n = 50) and post-acute (n = 47) STEMI groups. LA active emptying fraction (LAAEF) was higher in the acute-STEMI as compared with the post-acute STEMI groups (0.63 ± 0.23 vs 0.37 ± 0.24, p < 0.0001). Conversely, LA passive emptying fraction (LAPEF) was lower in the acute-STEMI compared with post-acute-STEMI (0.34 ± 0.15 vs 0.65 ± 0.15, p < 0.0001) patients. In the acute-STEMI group, LAAEF was positively and LAPEF negatively correlated with LV myocardial tissue damage (r = 0.523 p = 0.0001; r = - 0.451 p = 0.0013). Negative and positive correlations were also found between LAAEF and LAPEF and time after STEMI (r = - 0.559 p = 0.0013 and r = 0.589 p = 0.0006, respectively). LA increases its active contractile function in the acute phase of STEMI to support LV filling. The extent (but not the type) of LV damage determines LA adaptions which normalizes over time.

Prediction of nonviable myocardium by ECG Q-Wave parameters: A 3.0 T cardiovascular magnetic resonance study

IntroductionThe presence of a Q-wave on a 12-lead electrocardiogram (ECG) has been considered a marker of a large myocardial infarction (MI). However, the correlation between the presence of Q-waves and nonviable myocardium is still controversial. The aims of this study were to 1) test QWA, a novel ECG approach, to predict transmural extent and scar volume using a 3.0 Tesla scanner, and 2) assess the accuracy of QWA and transmural extent. MethodsConsecutive patients with a history of coronary artery disease who came for myocardial viability assessment by CMR were retrospectively enrolled. Q-wave measurements parameters including duration and maximal amplitude were performed from each surface lead. A 3.0 Tesla CMR was performed to assess LGE and viability. ResultsTotal of 248 patients were enrolled in the study (with presence (n = 76) and absence of pathologic Q-wave (n = 172)). Overall prevalence of pathologic Q-waves was 27.2% (for LAD infarction patients), 20.0 % (for LCX infarction patients), and 16.8% (for RCA infarction patients). Q-wave area demonstrated high performance for predicting the presence of a nonviable segment in LAD territory (AUC 0.85, 0.77–0.92) and a lower, but still significant performance in LCX (0.63, 0.51–0.74) and RCA territory (0.66, 0.55–0.77). Q-wave area greater than 6 ms mV demonstrated high performance in predicting the presence of myocardium scar larger than 10% (AUC 0.82, 0.76–0.89). ConclusionQ-wave area, a novel Q-wave parameter, can predict non-viable myocardial territories and the presence of a significant myocardial scar extension.

A Combined Echocardiography Approach for the Diagnosis of Cancer Therapy–Related Cardiac Dysfunction in Women With Early-Stage Breast Cancer

Diagnosis of cancer therapy-related cardiac dysfunction (CTRCD) remains a challenge. Cardiovascular magnetic resonance (CMR) provides accurate measurement of left ventricular ejection fraction (LVEF), but access to repeated scans is limited. To develop a diagnostic model for CTRCD using echocardiographic LVEF and strain and biomarkers, with CMR as the reference standard. In this prospective cohort study, patients were recruited from University of Toronto-affiliated hospitals from November 2013 to January 2019 with all cardiac imaging performed at a single tertiary care center. Women with human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer were included. The main exclusion criterion was contraindication to CMR. A total of 160 patients were recruited, 136 of whom completed the study. Sequential therapy with anthracyclines and trastuzumab. Patients underwent echocardiography, high-sensitivity troponin I (hsTnI), B-type natriuretic peptide (BNP), and CMR studies preanthracycline and postanthracycline every 3 months during and after trastuzumab therapy. Echocardiographic measures included 2-dimensional (2-D) LVEF, 3-D LVEF, peak systolic global longitudinal strain (GLS), and global circumferential strain (GCS). LVEF CTRCD was defined using the Cardiac Review and Evaluation Committee Criteria, GLS or GCS CTRCD as a greater than 15% relative change, and abnormal hsTnI and BNP as greater than 26 pg/mL and ≥ 35 pg/mL, respectively, at any follow-up point. Combinations of echocardiographic measures and biomarkers were examined to diagnose CMR CTRCD using conditional inference tree models. Among 136 women (mean [SD] age, 51.1 [9.2] years), CMR-identified CTRCD occurred in 37 (27%), and among those with analyzable images, in 30 of 131 (23%) by 2-D LVEF, 27 of 124 (22%) by 3-D LVEF, 53 of 126 (42%) by GLS, 61 of 123 (50%) by GCS, 32 of 136 (24%) by BNP, and 14 of 136 (10%) by hsTnI. In isolation, 3-D LVEF had greater sensitivity and specificity than 2-D LVEF for CMR CTRCD while GLS had greater sensitivity than 2-D or 3-D LVEF. Regression tree analysis identified a sequential algorithm using 3-D LVEF, GLS, and GCS for the optimal diagnosis of CTRCD (area under the receiver operating characteristic curve, 89.3%). The probability of CTRCD when results for all 3 tests were negative was 1.0%. When 3-D LVEF was replaced by 2-D LVEF in the model, the algorithm still performed well; however, its primary value was to rule out CTRCD. Biomarkers did not improve the ability to diagnose CTRCD. Using CMR CTRCD as the reference standard, these data suggest that a sequential approach combining echocardiographic 3-D LVEF with 2-D GLS and 2-D GCS may provide a timely diagnosis of CTRCD during routine CTRCD surveillance with greater accuracy than using these measures individually. ClinicalTrials.gov Identifier: NCT02306538.

Reference values of left and right atrial volumes and phasic function based on a large sample of healthy Chinese adults: A cardiovascular magnetic resonance study

BackgroundThe left and right atrial (LA and RA) size and function are tightly linked to the morbidity and mortality of multiple cardiovascular diseases. We aimed to establish cardiovascular magnetic resonance (CMR) reference values for LA and RA volumes and phasic function based on a large sample of healthy Chinese adults. Methods408 validated healthy Chinese adults (54% men; aged 21–70 years) were included. LA and RA maximum, minimum, and pre-atrial contraction volumes (Vmax, Vmin, and Vpac); total, passive, and booster emptying fractions (EF total, EF passive, and EF booster); and total, passive, and active emptying volumes (TEV, PEV, and AEV) were measured on cine CMR. Normal reference values were calculated and were stratified by sex and age decades. ResultsMen demonstrated greater LAVmax, LAVmin, LAVpac, LAPEV, RAVmax, RAVmin, RAVpac, RATEV, and RAAEV, while women had higher LAEF total, LAEF booster, RAEF total, RAEF passive, and RAEF booster (all p < 0.05). Age was positively correlated with LAVpac and RAVpac in both sexes but was positively correlated with LAVmax, LAVmin, RAVmax, and RAVmin only in women (all p < 0.05). For both sexes, aging was associated with decreased LAEF total, LAEF passive, RAEF total, and RAEF passive, but increased LAEF booster (all p < 0.05). ConclusionWe systematically provide age- and sex-specific CMR reference values for LA and RA volumes and phasic function based on a large sample of healthy Chinese adults with a wide age range. Both age and sex are closely associated with biatrial volumes and function.

Prognostic value of left atrioventricular coupling index (LACI) in pre- and post-menopausal women : from the multi-ethnic study of atherosclerosis (MESA)

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Although endogenous sex hormones influence both left atrial (LA) and left ventricular (LV) structure in peri-menopausal women, no study has ever evaluated the interaction between sex hormones levels and the left atrioventricular coupling. PURPOSE This study aimed to assess the prognostic value of a left atrioventricular coupling index (LACI) in pre- and post-menopausal women without history of CVD at baseline. METHODS In all women participating in the Multi-Ethnic Study of Atherosclerosis (MESA) with baseline cardiovascular magnetic resonance (CMR) study, LACI was measured as the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. Cox proportional hazard models were used to assess the association between LACI and the outcomes of atrial fibrillation (AF), heart failure (HF), coronary heart disease (CHD) death, and hard CVD defined by myocardial infarction, resuscitated cardiac arrest, stroke, or CHD death. In multivariable analyses, the associations between LACI and the time-to-event were evaluated, adjusting for demographics, traditional cardiovascular risk factors, menopausal status and sex hormone levels. RESULTS Among the 2,087 women (61.2 ± 10.1 years), 485 cardiovascular events were observed during mean follow-up period of 13.2 ± 3.3 years. Greater LACI was independently associated with AF (HR 1.70; 95% CI [1.51-1.90]), HF (HR 1.62; 95% CI [1.33-1.97]), CHD death (HR 1.36; 95% CI [1.10-1.68]), and hard CVD (1.30; 95% CI [1.13-1.51], all p &amp;lt; 0.001). Adjusted models with LACI showed significant improvement in model discrimination and reclassification compared to currently used standard models to predict the incidences of AF (C-statistic: 0.82 vs. 0.79; NRI = 0.325; IDI = 0.036), HF (C-statistic: 0.84 vs. 0.81; NRI = 0.571; IDI = 0.023), CHD death (C-statistic: 0.87 vs. 0.85; NRI = 0.506; IDI = 0.012), and hard CVD (C-statistic: 0.78 vs. 0.76; NRI = 0.229; IDI = 0.012). The prognostic value of LACI was homogeneous in both pre- and post-menopausal women with a better discrimination and reclassification compared to individual LA or LV parameters. CONCLUSIONS In a multi-ethnic population of pre- and post-menopausal women, LACI is an independent predictor of HF, AF, CHD death and hard CVD. In both pre- and post-menopausal women, LACI has an incremental prognostic value to predict cardiovascular events over traditional risk factors and sex hormone levels. ClinicalTrials.gov Identifier: NCT00005487 Abstract Figure. Kaplan-Meier curves by LACI terciles Abstract Figure. Kaplan-Meier curves by LACI and Menop.

Left atrial remodeling and the prognostic value of feature tracking derived left atrial strain in patients with light-chain amyloidosis: a cardiovascular magnetic resonance study.

Systemic light-chain (AL) amyloidosis is characterized by the aggregation of misfolded immunoglobulin light chain, predominantly infiltrating in the heart, including left atrium (LA). LA remodeling, such as increased interatrial septal thickness and enlarged size, has been observed. However, LA strain assessed by cardiac magnetic resonance feature tracking (CMR-FT) and its prognostic role remains to be further determined. Using CMR, the current study sought to investigate the characteristic of LA remodeling and the prognostic value of LA strain in patients with AL. Eighty-seven consecutive patients who underwent CMR with histologically confirmed systemic light-chain amyloidosis were retrospectively enrolled. LA strain parameters were analyzed based on CMR-FT algorithm. Amyloid infiltration and burden loads were assessed with CMR late gadolinium enhancement (LGE) and extracellular volume (ECV). Patients were categorized according to the extent of amyloid infiltration in cardiac myocardium. The primary endpoint was defined as all-cause mortality. The prognosis value of LA strain indices was evaluated using Cox proportional hazards regression and Kaplan-Meier curves. Interatrial septal thickness (3 [2-5] vs. 4 [3-5] mm, p = 0.007) and indexed LA volume (34.6 [26.9-44.6] vs. 50.5 [36.1-58.5] ml/m2, p = 0.001) were significantly higher in patients with atrial involvement (LA-LGE). Compared with patients with low amyloid burden loads (ECV group I), those at moderate and high (ECV group II and III) show progressive impairment in LA reservoir, conduit, and booster strains and strain rates. A total of 44 patients died during a median follow-up of 12months. In multivariate analysis, LA reservoir strain, New York Heart Association (NYHA), and ECV remained independently associated with survival. On Kaplan-Meier analyses, low LA reservoir strain (< 8.6%) increased the risk of mortality. In moderate amyloid burden loads patients, low LA reservoir strain provides additive prognosis value. Progress left atrial remodeling and dysfunction are common findings in AL cardiac amyloidosis. The CMR-FT-derived LA reservoir strain provides independent and additive prognostic value for all-cause mortality in patients with AL cardiac amyloidosis.

Cardiovascular magnetic resonance in children with suspected myocarditis: current practice and applicability of adult protocols.

Cardiovascular magnetic resonance serves as a useful tool in diagnosing myocarditis. Current adult protocols are yet to be validated for children; thus, it remains unclear if the methods used can be applied with sufficient image quality in children. This study assesses the use of cardiovascular magnetic resonance in children with suspected myocarditis. Image data from clinical cardiovascular magnetic resonance studies performed in children enrolled in Mykke between June 2014 and April 2019 were collected and analysed. The quality of the data sets was evaluated using a four-point quality scale (4: excellent, 3: good, 2: moderate, 1: non-diagnostic). A total of 102 patients from 9 centres were included with a median age (interquartile range) of 15.4(10.7-16.6) years, 137 cardiovascular magnetic resonance studies were analysed. Diagnostic image quality was found in 95%. Examination protocols were consistent with the original Lake Louise criteria in 58% and with the revised criteria in 35%. Older patients presented with better image quality, with the best picture quality in the oldest age group (13-18 years). Sedation showed a negative impact on image quality in late gadolinium enhancement and oedema sequences. No such correlation was seen in cardiac function assessment sequences. In contrast to initial scans, in follow-up examinations, the use of parametric mapping increased while late gadolinium enhancement and oedema sequences decreased. Cardiovascular magnetic resonance protocols for the assessment of adult myocarditis can be applied to children without significant constraints in image quality. Given the lack of specific recommendations for children, cardiovascular magnetic resonance protocols should follow recent recommendations for adult cardiovascular magnetic resonance.

Normal sex and age-specific parameters in a multi-ethnic population: a cardiovascular magnetic resonance study of the Canadian Alliance for Healthy Hearts and Minds cohort

BackgroundDespite the growing utility of cardiovascular magnetic resonance (CMR) for cardiac morphology and function, sex and age-specific normal reference values derived from large, multi-ethnic data sets are lacking. Furthermore, most available studies use a simplified tracing methodology. Using a large cohort of participants without history of cardiovascular disease (CVD) or risk factors from the Canadian Alliance for Healthy Heart and Minds, we sought to establish a robust set of reference values for ventricular and atrial parameters using an anatomically correct contouring method, and to determine the influence of age and sex on ventricular parameters.Methods and resultsParticipants (n = 3206, 65% females; age 55.2 ± 8.4 years for females and 55.1 ± 8.8 years for men) underwent CMR using standard methods for quantitative measurements of cardiac parameters. Normal ventricular and atrial reference values are provided: (1) for males and females, (2) stratified by four age categories, and (3) for different races/ethnicities. Values are reported as absolute, indexed to body surface area, or height. Ventricular volumes and mass were significantly larger for males than females (p < 0.001). Ventricular ejection fraction was significantly diminished in males as compared to females (p < 0.001). Indexed left ventricular (LV) end-systolic, end-diastolic volumes, mass and right ventricular (RV) parameters significantly decreased as age increased for both sexes (p < 0.001). For females, but not men, mean LV and RVEF significantly increased with age (p < 0.001).ConclusionUsing anatomically correct contouring methodology, we provide accurate sex and age-specific normal reference values for CMR parameters derived from the largest, multi-ethnic population free of CVD to date.Clinical trial registrationClinicalTrials.gov, NCT02220582. Registered 20 August 2014—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02220582.

Functional and structural reverse myocardial remodeling following transcatheter aortic valve replacement: a prospective cardiovascular magnetic resonance study

BackgroundSince cardiovascular magnetic resonance (CMR) imaging allows comprehensive quantification of both myocardial function and structure we aimed to assess myocardial remodeling processes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).MethodsCMR imaging was performed in 40 patients with severe AS before and 1 year after TAVR. Image analyses comprised assessments of myocardial volumes, CMR-feature-tracking based atrial and ventricular strain, myocardial T1 mapping, extracellular volume fraction-based calculation of left ventricular (LV) cellular and matrix volumes, as well as ischemic and non-ischemic late gadolinium enhancement analyses. Moreover, biomarkers including NT-proBNP as well as functional and clinical status were documented.ResultsMyocardial function improved 1 year after TAVR: LV ejection fraction (57.9 ± 16.9% to 65.4 ± 14.5%, p = 0.002); LV global longitudinal (− 21.4 ± 8.0% to -25.0 ± 6.4%, p < 0.001) and circumferential strain (− 36.9 ± 14.3% to − 42.6 ± 11.8%, p = 0.001); left atrial reservoir (13.3 ± 6.3% to 17.8 ± 6.7%, p = 0.001), conduit (5.5 ± 3.2% to 8.4 ± 4.6%, p = 0.001) and boosterpump strain (8.2 ± 4.6% to 9.9 ± 4.2%, p = 0.027). This was paralleled by regression of total myocardial volume (90.3 ± 21.0 ml/m2 to 73.5 ± 17.0 ml/m2, p < 0.001) including cellular (55.2 ± 13.2 ml/m2 to 45.3 ± 11.1 ml/m2, p < 0.001) and matrix volumes (20.7 ± 6.1 ml/m2 to 18.8 ± 5.3 ml/m2, p = 0.036). These changes were paralleled by recovery from heart failure (decrease of NYHA class: p < 0.001; declining NT-proBNP levels: 2456 ± 3002 ng/L to 988 ± 1222 ng/L, p = 0.001).ConclusionCMR imaging enables comprehensive detection of myocardial remodeling in patients undergoing TAVR. Regression of LV matrix volume as a surrogate for reversible diffuse myocardial fibrosis is accompanied by increase of myocardial function and recovery from heart failure. Further data are required to define the value of these parameters as therapeutic targets for optimized management of TAVR patients.Trial registration DRKS, DRKS00024479. Registered 10 December 2021—Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024479