Contrast-enhanced Cardiac MRI Research Articles

Combined Heart Injuries on the Data of Contrast-Enhanced Cardiac Magnetic Resonance Imaging in Patients With Post-Covid Syndrome.

Aim Prospective assessment of the nature of cardiac injury in patients with post-COVID syndrome according to contrast-enhanced MRI in routine clinical practice.Material and methods 106 previously unvaccinated patients were evaluated. 62 (58.5%) of them were women with complaints that persisted after COVID-19 (median age, 57.5 [49; 64] years). In addition to standard indexes, markers of inflammation and myocardial injury were determined, and cardiac contrast-enhanced MRI was performed in each patient.Results The median time from the onset of COVID-19 to cardiac MRI was 112.5 [75; 151] days. The nature of cardiac injury according to MRI in patients with post-COVID syndrome was complex and included a decrease in left ventricular (LV) and right ventricular ejection fraction, pericardial effusion, and pathological foci of late and early contrast enhancement at various locations. In 29 (27.4%) cases, there was a combination of any two signs of heart injury. In 28 (26.4%) patients with focal myocardial injury during the acute phase of COVID-19, hydroxychloroquine and tocilizumab were administered significantly more frequently, but antiviral drugs were administered less frequently. The presence of focal myocardial injury was associated with pathological LV remodeling.Conclusion According to contrast-enhanced cardiac MRI, at least 27.4% of patients with post-COVID syndrome may have signs of cardiac injury in various combinations, and in 26.4% of cases, foci of myocardial injury accompanied by LV remodeling are detected. The nature of heart injury after COVID-19 depends on the premorbid background, characteristics of the course of the infectious process, and the type of prescribed therapy. An algorithm for evaluating patients with post-COVID syndrome is proposed.

Myocardial Fibrosis in Sickle Cell Anemia

Introduction Cardiovascular disease is a leading cause of morbidity and mortality in patients with sickle cell disease (SCD) as they age.Contrast-enhanced cardiac MRI has been utilized to evaluate myocardial fibrosis by calculating the extracellular matrix volume fraction (ECV) from pre and post-contrast T1 mapping. Recent research in both animal and human models reveal that SCD patients have elevated ECV suggestive of myocardial fibrosis and is associated with diastolic dysfunction. The effects of current first-line therapies, chronic transfusions (CTT) or hydroxyurea (HU), on myocardial fibrosis are unknown and at present, there is conflicting data regarding their benefits. At our institution, SCD patients are treated early with either hydroxyurea, chronic transfusions, or both. We aimed to determine whether current disease-modifying therapies differentially affect myocardial fibrosis. Methods This was a single-center, retrospective cohort study of chronically transfused SCD patients and SCD patients on HU and/or CTT at Children's Hospital of Los Angeles between 2017 and 2022 aiming to assess clinical biomarkers associated with elevated ECV in sickle cell disease. This study was reviewed and approved by the Children's Hospital Los Angeles Institutional Review Board. All patients underwent cardiac MRI for clinical assessment of myocardial iron, cardiac enlargement, and myocardial fibrosis. Continuous variables are expressed as mean±standard deviation for normally distributed data and median [interquartile range] for non-normally distributed data. Parametric and non-parametric testing were used where appropriate and c-square testing was used for categorical variables. Results A total of 63 SCD patients, mean age 17.3±5.9 years (range 5-36yo), who underwent contrast-enhanced cardiac MRI imaging between 2017 and 2022 were included in this study: 27 CTT; 43 HU; and 7 healthy participants, mean age 15.4±2.4 years. There was no difference in age between treatment groups, nor healthy and SCD participants. There were 6 SCD patients not on any therapy and 13 patients on both. The ECV was elevated in SCD versus healthy (31.3% [27.9, 35] vs 26% [23.7,27.2], P=0.0003). There was no significant difference between the ECV values of patients on CTT, HU, both or no therapy, P=0.56 (Fig.1A). There was no difference in average length of therapy between CTT or HU, mean 10.4±4.9 vs 10.2±5.2 years and no association between length of therapy and ECV. We found positive correlation of E/A ratio with ECV in patients with SCD regardless of therapy (Spearmans rho 0.34, P=0.008), suggesting an association with left ventricular (LV) restrictive physiology. ECV was associated with increased WBC count (rho +0.28, P=0.03), AST (rho +0.3, P=0.02), decreased GFR (P=0.02), and decreased hemoglobin (rho -0.41, P=0.0013) (Fig.1B), while there was a trend toward increased urine microalbumin (rho +0.41, P=0.09). Discussion Fibrosis is likely due to prolonged, continuous exposure to inadequate myocardial oxygen supply and cardiac microvascular disease. Amelioration of myocardial fibrosis likely requires consistent, effective CTT or HU therapy as suggested by the Cincinnati/CHLA study. The HU patients in that study had documented high MCV or HbF over many years before ECV was measured. St Jude's study was prospective but follow-up was only 2 years and not compared to an untreated or poorly treated cohort. The sum of these studies suggests that protection from fibrosis may only be seen with continual protection from anemia/microvascular disease. This hypothesis remains to be proven. While we did not see a differential effect of hydroxyurea vs. chronic transfusion therapy, it is important to put this data into the context of SCD therapies and their indications. CTT is generally reserved for the most severe vascular disease phenotypes, such as stroke. Hydroxyurea is often prescribed but not always adhered to. The ECV range in our cohort was lower than that found in the original Cincinnati cohort, mean 44%±8, but similar to that found in the St. Jude cohort, median 30% [IQR 28,34] (Fig.1A). Lastly, elevated ECV correlates with anemia, a modifiable risk factor; restrictive LV physiology; and decreased estimated GFR, which may hint at similar etiologies. In summary, ECV is a clinically relevant cardiovascular biomarker and current preventative therapies may ameliorate but not abrogate myocardial fibrosis.

Abstract 15315: Cardiac MRI Tissue Characterization for Intra-Cardiac Thrombi Therapeutic Response in Systemic Cancer Patients

Introduction: Cardiac MRI (CMR) is often used to identify thrombi (C THR ) based on absence of contrast enhancement but its utility as a predictor of therapeutic response of anticoagulation (AC) is unknown. Methods: Adult (≥18yo) pts with systemic cancer were matched 1:1 for cancer etiology/stage and presence/absence of C THR on CMR. Cine-CMR assessed cardiac structure/function and localization of C THR . Contrast-enhanced CMR (0.2 mmol/kg gadolinium) was performed for identification of C THR and quantitative tissue properties. C THR resolution was evaluated on serial TTE at a time point of 3 months post CMR; clinical f/u and anticoagulation therapy were determined by chart review. Results: 189 pts (54±16 yo; 50% M) were studied, 106 with C THR and 83 without. Cancer etiology varied (heme 30%

Abstract 18714: Myocardial Infarction With Non-Obstructive Coronary Artery Disease in a Young Woman - The Cardinal Role of Coronary Reactivity Testing in Unveiling the Underlying Etiology

43-year old female presented to the emergency department with substernal chest pain. She had similar symptoms years ago without obstructive CAD on coronary angiogram and was diagnosed with myocarditis. Presenting ECG revealed new anterolateral T wave inversions (Fig 1), and high-sensitivity troponins peaked at 322 ng/L consistent with NSTEMI. TTE was significant for global hypokinesis of the left ventricle with a reduced ejection fraction of 35 to 40%. Invasive coronary angiogram showed no obstructive CAD or spontaneous coronary artery dissection however there was reduced flow in the mid to distal LAD raising suspicion for endothelial and microvascular dysfunction. Contrast-enhanced cardiac MRI showed myocardial edema in the anterior and anteroseptal walls with elevated myocardial T1 and T2 values, and early enhancement post gadolinium administration showed an acute LAD territorial infarct (Fig 2). Findings were consistent with myocardial infarction with non-obstructive coronary artery disease (MINOCA). She was started on carvedilol for empiric treatment of coronary artery spasm and microvascular dysfunction, along with aspirin and atorvastatin. Losartan was added for heart failure management. Outpatient invasive coronary reactivity testing showed severe epicardial (70% vasoconstriction) and microvascular (80% decrease in coronary blood flow) endothelial dysfunction in response to acetylcholine (Fig 3 and Fig 4) as underlying etiology of recent MINOCA. CFR was normal. L-arginine (NO precursor) was added to the medical regimen. Patient has not had recurrence of chest pain or ACS at 1 year follow-up and LVEF normalized on repeat echocardiogram. This case shows the importance of cardiac MRI in confirming the diagnosis of MINOCA in patients with no obstructive CAD, and the crucial role of coronary reactivity testing in diagnosing and treating severe coronary endothelial dysfunction, which is aligned with the AHA/ACC MINOCA consensus document.

Abstract 15293: Impact of Catheter on Central Venous Catheter Associated Right Atrial Thrombosis in Systemic Cancer Patients

Introduction/Background: Central venous catheters (CVC) are commonly utilized in cancer patients for prolonged systemic anti-cancer treatments but increased the risk of right atrial thrombosis (C THR ). Cardiac MRI (CMR) tissue characterization is commonly performed to identify C THR based on absence of vascularity. Research Questions/Hypothesis: How do catheters affect thrombus formation? Goals/Aims: To evaluate predictors of thrombus formation in cancer patients with CVC. Methods/Approach: The population comprised of adult (≥18yo) systemic cancer pts with indwelling CVC who underwent contrast-enhanced CMR (0.2 mmol/kg gadolinium). C THR were defined using the reference of LGE-CMR via established criteria (absence of contrast enhancement). CVC depth was measured from CXR/CT. Clinical follow-up was obtained via chart review for embolic events. Results/Data (descriptive and inferential statistics): 157 cancer pts with CVC (52±17 yo; 47% M; heme 29%

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.

PO-02-182 OCCURRENCE OF PERICARDIAL AND INTRA-PERICARDIAL SPACE EFFUSIONS WITH PROTON BEAM ABLATION

With large lesion formation, there is a possibility of perforation or other cardiac related tissue changes. These have not been well evaluated in a in situ model. The purpose of this study was to evaluate the pericardial effusion after pencil-beam scanned proton therapy on normal myocardium in swine in MRI. Therefore, 32 domestic swine underwent proton beam ablation to the left ventricle anterior wall, posterior wall, and apex. Each swine was subjected to monthly contrast-enhanced cardiac MRI to evaluate the post-irradiation effects. Importantly, the typical dose delivered after contouring, simulations, and treatment planning was between 30 and 40 Gy. With these deliveries, a pericardial effusion was seen in 18 swine. These were first seen 4 weeks after the radiation and showed resolution in 87% within 14 days. Actual pericarditis was seen in 2 pigs after the ablation. There was no evidence of dissection of myocardial tissue, nor steam pops or their equivalent with particle therapy. The animals appeared to show no distress or irritation. With the pathology at the time of study showed no presence of pericarditis and no other complications. Also, there was significant correlation between animals with mean dose to myocardium and the grade of PE. As such, pericardial effusions may occur in the setting of particle therapy. Of note, these are minor however and do not appear to be of clinical significance. Still, this suggests the need for careful monitoring of animals in the post-procedure setting.

Detection of brief atrial fibrillation in continuous 12-lead ECG recordings using an algorithm for computerized resting ECG interpretation combined with convolutional neural network for reducing false detections

Existing criteria recommended by ACC/ESC for identifying patients with ST elevation myocardial infarction (STEMI) from the 12-lead ECG perform with high specificity (SP), but low sensitivity (SE). In our previous studies, we found that the SE of ischemia detection can be markedly improved without any loss of SP by calculating, from the 12-lead ECG, ST deviation in 3 “optimal” vessel-specific leads (VSLs). Our original VSLs, based on ΔST body-surface potential maps (BSPMs), have been modified by using the more appropriate J-point BSPMs at peak ischemia (without subtraction of pre-occlusion distributions). The aim of the present study was to compare the performance of these new VSLs with that achieved by the STEMI criteria used in current practice.Two independent datasets of 12-lead ECGs were used: the STAFF III dataset acquired during ischemic episodes caused by balloon inflation in LAD (n = 35), RCA (n = 47), and LCx (n = 17) coronary arteries, and the Glasgow dataset comprising admission 12-lead ECGs of 116 patients who were hospitalized for chest pain and underwent contrast-enhanced cardiac MRI that confirmed AMI in 58 patients (50%).We found that, in the STAFF III dataset, the detection of ischemic state by the STEMI criteria attained SE/SP of 60/97%, whereas SE/SP values of VSLs were 72/98%. In the Glasgow dataset, STEMI criteria yielded SE/SP of 43/98%, whereas the VSLs improved SE/SP to 60/98%. The most significant increase in diagnostic performance appeared in patients with LCx coronary artery occlusion: in STAFF III data (n = 17) SE achieved by STEMI criteria was improved by the VSLs from 35% to 71%; in Glasgow data (n = 12) SE of 31% achieved by STEMI criteria was improved by the VSLs to 69%.In our study population, existing ACC/ESC STEMI criteria complemented by the new VSLs yielded much improved sensitivity of ischemia detection without any detrimental effect on specificity. This finding needs to be corroborated on a larger chest-pain patient population with typical prevalence of acute ischemia presented to the emergency rooms.

Temporal Uncertainty Localization to Enable Human-in-the-Loop Analysis of Dynamic Contrast-Enhanced Cardiac MRI Datasets.

Dynamic contrast-enhanced (DCE) cardiac magnetic resonance imaging (CMRI) is a widely used modality for diagnosing myocardial blood flow (perfusion) abnormalities. During a typical free-breathing DCE-CMRI scan, close to 300 time-resolved images of myocardial perfusion are acquired at various contrast "wash in/out" phases. Manual segmentation of myocardial contours in each time-frame of a DCE image series can be tedious and time-consuming, particularly when non-rigid motion correction has failed or is unavailable. While deep neural networks (DNNs) have shown promise for analyzing DCE-CMRI datasets, a "dynamic quality control" (dQC) technique for reliably detecting failed segmentations is lacking. Here we propose a new space-time uncertainty metric as a dQC tool for DNN-based segmentation of free-breathing DCE-CMRI datasets by validating the proposed metric on an external dataset and establishing a human-in-the-loop framework to improve the segmentation results. In the proposed approach, we referred the top 10% most uncertain segmentations as detected by our dQC tool to the human expert for refinement. This approach resulted in a significant increase in the Dice score (p < 0.001) and a notable decrease in the number of images with failed segmentation (16.2% to 11.3%) whereas the alternative approach of randomly selecting the same number of segmentations for human referral did not achieve any significant improvement. Our results suggest that the proposed dQC framework has the potential to accurately identify poor-quality segmentations and may enable efficient DNN-based analysis of DCE-CMRI in a human-in-the-loop pipeline for clinical interpretation and reporting of dynamic CMRI datasets.

Toxic myocarditis presenting as an acute coronary syndrome

BackgroundAcute myocarditis is one of the causes of acute non-ischemic myocardial injury mimicking acute coronary syndrome (ACS) on presentation. It is usually underdiagnosed due to the non-specificity of presenting symptoms, elevated troponin levels, and abnormal ECG (electrocardiogram) findings. Delayed contrast-enhanced cardiac MRI (CMR) is known as the gold standard imaging modality for differentiating acute non-ischemic myocardial injury from infarcted myocardium. The most frequent cause of myocarditis is viral infections, but further infrequent causes include other infectious pathogens, toxins, hypersensitivity drug reactions, and autoimmune diseases. Cannabis is one of the most abused illicit and recreational drugs in the world among adolescents and adults. Also, many reports of marijuana-associated cardiovascular risks have been established previously, mainly presenting as arrhythmias, myocardial infarction, and myocarditis.Case presentationA 19-year-old female, complaining of radiating chest pain to the left arm and jaw, along with associated sweating for 1 day. Initial work-up showed elevated troponin levels with ST segment elevation on ECG. On further investigation, CMR showed findings of myocarditis and negative virology work-up led to a work-up of proper history, which revealed marijuana abuse, with a history of consumption 3 days before presentation. Hence, it was diagnosed as toxic myocarditis secondary to presumed cannabis abuse and treated for same.ConclusionsNon-ischemic myocardial injury causes like myocarditis should be considered in young patients especially, who are presenting to emergency with ACS. CMR should be used as a first line diagnostic imaging modality (based on its availability) in cases mimicking an ACS or suspected myocarditis, especially in young patients. Though viral etiology is considered the most common cause of myocarditis, less common causes such as toxic myocarditis must be considered in cases of young individuals presenting with ACS in an emergency.

Abstract 11620: Time Course of Pericardial Effusion After Catheter-Free Ventricular Ablation With Proton Beam in Swine Normal Heart

Background: Cardiac proton beam ablation therapy has emerged as a promising tool for catheter-free arrhythmia ablation. The time course of the lesion change was demonstrated in MRI 8 weeks following the ablation; however, the pericardial effusion after the ablation has not been fully analyzed. Objective: The purpose of this study was to evaluate the pericardial effusion after pencil-beam scanned proton therapy on normal myocardium in swine in MRI. Methods: 32 domestic swine were irradiated with pencil-beam scanned proton therapy using irradiation doses of 30/40Gy to the left ventricle (LV) anterior wall, posterior wall, and apex. Each swine was subjected to monthly contrast-enhanced cardiac MRI to evaluate the post-irradiation effects. Results: Moderate to significant pericardial effusion (PE) was observed in 10 swine (31%), starting at 4 weeks, and increasing from 8-16 weeks until 24 weeks. With the exception of one case,, improvement was observed in all animals within a month from when the PE first became moderate or significant. . In the case where the significant PE did not improve, the PE was non-septic and transudate. Clinically, the PE did not cause cardiac tamponade and did not correlate to sudden death. Also, there was no correlation between animals with larger tissue volumes receiving higher dose (more than 20Gy) and the grade of PE . Conclusion: Proton beam radiation caused various grades of pericardial effusion, but in 90% of the animals, it resolved without intervention within a month with no major adverse events.

Role of MRI in evaluation and characterization of neoplastic and nonneoplastic cardiac masses

BackgroundThe overall frequency of cardiac tumors is quite low, with an estimated cumulative prevalence of 0.002–0.3% at autopsy, however, they represent an important group of cardiovascular abnormalities as the early and accurate diagnosis maybe curative and sometimes avoids unnecessary surgery.Aim and objectivesThe aim of this study was to evaluate the efficacy of MRI, in diagnosis, evaluation, and characterization of cardiac neoplasms, as identification and differentiation between the cardiac masses are of extreme importance to develop exquisite better therapeutic planning and positive prognostic results.Patients and methodsThis study is a prospective one that was conducted on 27 patients who were diagnosed to have cardiac masses by echocardiography or other imaging modalities. Contrast-enhanced MRI was done on closed Siemens MR Systems operating at 1.5 T in National Heart Institute in Giza. The study was performed after approval of the Ethical Committee of Scientific Research. Evaluation of cardiac masses was analyzed, regarding the involved chambers, pericardial violation, morphological characters, as well as their pattern of enhancement at contrast-enhanced cardiac MRI studies, aiming at characterization of different cardiac masses on MRI diagnostic bases.ResultsIn our study, we diagnosed 85.2% (23/27) of the cases as benign-looking lesions (including both true and pseudotumors), while 14.8% (4/27) as malignant-looking lesions. A statistical significant difference was noted, regarding the differentiation between the benign and the malignant lesions regarding the size, marginal outline, pattern of growth, and pericardial affection, either infiltration or effusion. As regards the pericardial affection, none of the benign lesions showed pericardial infiltration compared with 50% (2/4) of the malignant lesions that showed pericardial infiltration with a statistically significant P value of 0.017.ConclusionCardiac magnetic resonance imaging (CMR) has a great role in evaluation of the cardiac masses by its powerful assessment of the anatomical and soft-tissue characterization of the masses, as well as their functional impact, and so it allows the differentiation between neoplastic and nonneoplastic masses, as well as between malignant and benign masses.

Patterns of Replacement Fibrosis in Hypertrophic Cardiomyopathy.

Background Myocardial replacement fibrosis is one of the major histologic features of hypertrophic cardiomyopathy (HCM), but its characteristics have not been well delineated. Purpose To clarify the characteristics of replacement fibrosis in HCM and to evaluate the prognostic value of the regional extent of fibrosis. Materials and Methods This prospective study evaluated participants with HCM who underwent contrast-enhanced cardiac MRI from March 2011 to April 2019. For each participant, global and 16-segment extent of late gadolinium enhancement (LGE) in the left ventricle (LV) at cardiac MRI was analyzed. The primary end point was all-cause death. Results Among the 798 study participants enrolled (median age, 49 years [interquartile range {IQR}: 38-59 years]; 508 men), 588 (74%) underwent whole-exome sequencing. Thirty-five participants (4%) experienced death from any cause during a median follow-up of 2.9 years (IQR: 1.5-4.7 years). Spearman analysis showed weak correlations between the extent of LGE and wall thickness (LGE of global LV and maximal LV wall thickness, r = 0.35 [P < .001]; LGE and thickness of septum, r = 0.30 [P < .001]). In the 16-segment model, the distribution of LGE was visually inhomogeneous and higher in the basal anterior, basal septal, midanterior, and midseptal regions (P < .001). This similar distribution of LGE was observed in participants with asymmetric septal hypertrophy, those with apical HCM, participants positive for mutation and those negative for mutation, and participants with MYH7 and MYBPC3 mutations. Cox analysis indicated that both the global extent of LGE (adjusted hazard ratio = 1.68 per 10% increase in LGE; P < .001) and the regional extent of LGE (ie, basal, midventricular, and apical regions of LV when on the short-axis view; septum, anterior free wall, inferior free wall, and lateral free wall when on the long-axis view) were associated with adverse outcomes. Conclusion In hypertrophic cardiomyopathy, myocardial replacement fibrosis weakly correlated with hypertrophy, was inhomogeneous and asymmetric, and was predominantly distributed in the interventricular septal wall and anterior free wall at the basal and mid levels. Greater extent of fibrosis was associated with poor prognosis, regardless of its location in the left ventricle. © RSNA, 2021 See also the editorial by Hanneman in this issue.

The relationship between coronary anatomy and primary percutaneous coronary intervention features and prognostically unfavorable CMR-based characteristics of acute ST-elevation myocardial infarction

Abstract Purpose To investigate the impact of coronary anatomy and pPCI parameters on the most prognostically significant MRI measures of acute MI with ST segment elevation (MVO, infarct size). Methods The study included 52 patients with STEMI and primary percutaneous coronary intervention (pPCI) of infarct-related arteries (IRA). On Days 3–7 contrast-enhanced cardiac MRI was done. Tissue analysis of scans was performed evaluating infarct size, presence and size of MVO. Results The study included 52 patients with first STEMI within &amp;lt;48 hours of onset. All patients urgently underwent pPCI for reperfusion. Patients were divided into 2 groups separated by the median time to reperfusion treatment (3 hours). There were no significant differences between groups in MRI-measured EF (In the group with later pPCI (&amp;gt;3 hours of symptom onset EF was 49.0±11.0%, and in the comparator group – 45.7±10.5%, p=0,2). MRI-measured infarct size was significantly higher in the group where pPCI was done &amp;gt;3 hours of symptom onset: 18.1±1.7% of the LV mass, compared to the early reperfusion group – 10.9±1.9% (p=0.009). MVO magnitude was also higher in the later pPCI group (2.6±0.64% vs 0.03±0.3% in the comparator group), (p&amp;lt;0,027). Correlation analysis also revealed a reliable relationship between IS and time to reperfusion (R 0.381, p=0.006). LAD lesions were associated with higher infarct size values (p=0.02) and higher risk of MVO (odds ratio 2.9, CI 0.83–10.0, p=0.03). Complete occlusion of IRA was associated with higher IS (16,97±3.3 vs 12.05±1.4, p=0.02). There was no reliable correlations between IRA patientcy and MVO magnitude (p=0.7). Conclusions In this study pPCI timing, in groups of below and more than 3 hours after symptom onset, had no significant impact on EF, as determined by MRI. However, pPCI timing exceeding 3 hours significantly influenced infarct size, the occurrence and magnitude of microvascular obstruction. LAD being the IRA was associated with larger IS, higher risks of MVO development. Patient IRA was associated with smaller IS as determined by MRI. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Healthcare Russian Federation

Analysis of risk factors for prognostically unfavorable MI features as determined by cardiac MRI with contrast enhancement

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): A.L. Myasnikov Institute of Clinical Cardiology, Russian Cardiology Research and Production Complex, Ministry of Health of Russia, Moscow, Russia Background A growing number of publications describe the role of cardiac MRI in STEMI prognostic assessment. Infarct size, microvascular obstruction (MVO) and myocardial heterogeneity are among the most prognostically significant MRI parameters in MI. Primary PCI (pPCI) is the current standard of STEMI treatment. The impact of clinical factors on the development of MVO, myocardial heterogeneity and infarct size remains insufficiently investigated. Purpose To investigate the impact of certain medical history aspects, clinical and laboratory parameters on the most prognostically significant MRI measures of acute MI (MVO, infarct size, myocardial heterogeneity). Methods The study included 52 patients with first STEMI within &amp;lt;48 hours of onset. All patients urgently underwent coronary angiography with pPCI of infarct-related arteries (IRA). On Days 3-7 contrast-enhanced cardiac MRI was done. Tissue analysis of scans was performed using CVI 42 software evaluating infarct size, MVO, myocardial heterogeneity, and left ventricle (LV) ejection fraction (EF). Results 85% patients were men, with mean age of 59.09 ± 7.7 years. All patients underwent pPCI for reperfusion. The median time from symptom onset to pPCI was 3 hours.  We analyzed the influence clinical and laboratory factors impacting cardiovascular prognosis on the development of MVO, infarct size, and myocardial heterogeneity. Odds ratios demonstrated no significant relationship between arterial hypertension (OR 2.10, CI 0.57-7.79 р=0,2), smoking (OR 1.01 CI 0.32-3.20, р=0.9), obesity defined as BMI &amp;gt;30 kg/m2) (OR 0.83 CI 0,50-1.39, р=0.16) and MVO development. However, diabetes mellitus had significant effect on MVO development (OR 4.34 CI 1.34-14.03, р=0.01). With regards to laboratory parameters, relationship between hs-Troponin elevation &amp;gt; &amp;gt;8400 pg/mL and MVO occurrence (OR 7.00, CI 0.79 – 61.74, р=0.04). Correlation analysis demonstrated association between myocardial heterogeneity and BNP (r 0.612, р&amp;lt;0.0001), as well as advanced age (r 0,544, р&amp;lt;0,0001). Inverse correlation was found between myocardial heterogeneity and LV EF (r -0.461, р=0.0006). We also analyzed the factors associated with infarct size and found correlation between this parameter and BNP levels (r 0,553, p = 0,0003), as well as MVO magnitude (r 0,383, p = 0,005). Inverse correlation was found between infarct size and history of hypertension (r -0.380, p = 0.0054) Conclusions Type 2 diabetes mellitus, was found to be an independent predictor of microvascular obstruction on MRI. Elevation of hs-Troponin &amp;gt;8400 pg/mL was found to be associated with MVO development. Correlation data analysis demonstrated that high BNP may indicate higher infarct size and myocardial heterogeneity values (r 0.612, р&amp;lt;0.0001).

Biventricular Strain Imaging with Cardiac MRI in Genotyped and Histology Validated Amyloid Cardiomyopathy.

Cardiac amyloidosis (CA) is a common and potentially fatal infiltrative cardiomyopathy. Contrast-enhanced cardiac MRI (CMR) is used as a diagnostic tool. However, utility of CMR for the comprehensive analysis of biventricular strains and strain rates is not reported as extensively as echocardiography. In addition, RV strain analysis using CMR has not been described previously.Objectives:We sought to study the global and regional indices of biventricular strain and strain rates in endomyocardial biopsy (EMB)-proven, genotyped cases of CA.Methods:A database of 80 EMBs was curated from 2012 to 2019 based on histology. A total of 19 EMBs positive for CA were subjected to further tissue-characterization with histology, and compared with four normal biopsy specimens. Samples were genotyped for ATTR- or AL-subtypes. Five patients, with both echocardiography and contrast-enhanced CMR performed 72-h apart, were subjected to comprehensive analysis of biventricular strain and strain-rates.Results:Histology confirmed that the selected samples were indeed positive for cardiac amyloid. Echocardiography showed reduced global and regional left-ventricular (LV) longitudinal strain indices. CMR with tissue-characterization of LV showed global reductions in circumferential, radial and longitudinal strains and strain-rates, following a general trend with the echocardiographic findings. The basal right-ventricular (RV) segments had reduced circumferential strains with no changes in longitudinal strain.Conclusions:In addition to providing a clinical diagnosis of CA based on contrast clearance-dynamics, CMR can be a potent tool for accurate functional assessment of global and regional changes in strain and strain-rates involving both LV and RV. Further studies are warranted to validate and curate the strain imaging capacity of CMR in CA.

ВЗАИМОСВЯЗЬ СТРУКТУРНЫХ ИЗМЕНЕНИЙ МИОКАРДА У БОЛЬНЫХ ОСТРЫМ ИНФАРКТОМ МИОКАРДА С ПОДЪЕМОМ СЕГМЕНТА ST ПО ДАННЫМ КОНТРАСТНОЙ МРТ С ОСОБЕННОСТЯМИ КОРОНАРНОГО ПОРАЖЕНИЯ И ВРЕМЕНЕМ РЕПЕРФУЗИОННОЙ ТЕРАПИИ

Purpose. To study the relationship between the characteristics of acute myocardial infarction and ST-segment elevation (infarction size, microvascular obstruction) according to contrast cardiac MRI data with the features of coronary lesion and the time of percutaneous coronary intervention. Methods. The study included 52 patients with acute ST-segment elevation myocardial infarction (MI) who were admitted to the hospital in the first 48 hours after the onset of the disease and underwent primary percutaneous coronary intervention (pPCI). On Days 3-7 contrast-enhanced cardiac MRI was done. Tissue analysis of scans was performed evaluating infarct size, presence and size of microvascular obstruction (MVO). Results. Patients were divided into 2 groups separated by the median time to reperfusion treatment (3 hours). There were no significant differences between groups in MRImeasured ejection fraction (EF) (in the group with later pPCI &gt;3 hours of symptom onset EF was 49.0 ± 11.0%, and in the comparison group – 45.7 ± 10.5%, р=0,2). MRI-measured infarct size was significantly higher in the group where pPCI was done &gt;3 hours of symptom onset: 18.1 ± 1.7% of the left ventricular mass, compared to the early reperfusion group – 10.9 ± 1.9% (р=0.009). MVO magnitude was also higher in the later pPCI group (2.6 ± 0.64% vs 0.03 ± 0.3% in the comparator group), (р&lt;0,027). Correlation analysis also revealed a reliable relationship between infarct size and time to reperfusion (R 0.381, p=0.006). LAD lesions were associated with higher infarct size values (p=0.02) and higher risk of MVO (odds ratio 2.9, CI 0.83-10.0, р=0.03). Complete occlusion of infarct-related artery (IRA) was associated with higher infarct size (16,97±3.3 vs 12.05±1.4, р=0.02). There was no reliable correlations between IRA patientcy and MVO magnitude (р=0.7). Conclusions. In this study timing primary percutaneous coronary intervention, in groups of below and more than 3 hours after symptom onset, had no significant impact on ejection fraction, as determined by MRI. However, primary percutaneous coronary intervention timing exceeding 3 hours significantly influenced infarct size, the occurrence and magnitude of microvascular obstruction. LAD being the infarct-related artery was associated with larger infarct size, higher risks of microvascular obstruction development. The absence of complete occlusion of the infarct-related artery was associated with a smaller myocardial infarction size according to MRI data.

Role of free-breathing motion-corrected late gadolinium enhancement technique for image quality assessment and LGE quantification

ObjectiveTo compare the image quality and late gadolinium enhancement (LGE) quantification between free-breathing motion-corrected and conventional breath-hold LGE method in a variety of cardiovascular diseases. Materials and Methods149 consecutive patients underwent contrast-enhanced cardiac magnetic resonance examination employing both free-breathing motion-corrected LGE and conventional breath-hold LGE method. Scan time, contrast-to-noise ratio, overall image quality score and LGE mass were measured and analyzed statistically. ResultsFree-breathing motion-corrected LGE method had a shorter scan time and higher overall image quality score in comparison with conventional breath-hold LGE method (p < 0.001). Univariate/multivariate logistic regression analysis showed that breath-holding difficulty, high heart rate and arrhythmia could be predictive factors possibly for an inferior image quality score (p < 0.05 for all). The contrast-to-noise ratios of free-breathing motion-corrected LGE images were higher than those of conventional breath-hold LGE images (p < 0.001). In the cases with subepicardial and/or transmural myocardial enhancement, the measured LGE masses were larger on free-breathing motion-corrected LGE images in comparison with those on conventional breath-hold LGE images (p < 0.05). ConclusionFree-breathing motion-corrected LGE could be a better choice for patients who need contrast-enhanced cardiac MRI and have one or more of the risk factors for an inferior image quality score, including breath-holding difficulty, high heart rate and arrhythmia. However, an overestimation of LGE mass on free-breathing motion-corrected LGE image should be taken into consideration when LGE pattern involves subepicardial and/or transmural myocardium.

P731 When cardiac imaging saves the day - a rare cause of embolic stroke

Abstract INTRODUCTION Hypereosinophilic syndrome (HES) is a rare disorder characterised by infiltration of tissues by eosinophils. Myocardial infiltration occurs in 50-60% of HES and leads to a condition called Loeffler’s endocarditis. Eosinophilic protein toxicity initiates endomyocardial necrosis. This is followed by a thrombotic stage and finally by endomyocardial fibrosis leading to a form of restrictive cardiomyopathy. Thrombosis is often located in the apical region of the ventricles and can result in stroke, which is the most devastating neurological consequence of hyperoesinophilia. We describe a case of a patient that presented with neurological symptoms and was found to have multiple embolic strokes secondary to Loeffler’s endocarditis. CASE A 57-year-old female presented to our institution with new onset confusion and reduced level of consciousness. Initial neurological assessment was consistent with encephalopathy. She had a 2-year history of eosinophilia that had been investigated by the haematology and rheumatology teams with no obvious aetiology identified. Initial haematological investigations showed a raised eosinophil count at 13mmol/L. Her cerebral MRI scan showed multiple embolic infarcts and therefore a transthoracic echo (TTE) was booked. This did not show any obvious intracardiac cause of emboli although the appearances of the LV apex were suspicious of thrombus. This was confirmed later, on contrast imaging (Fig 1). Staphylococcus aureus was grown in a single blood culture specimen raising the suspicion of infective endocarditis and a transoeosophageal echocardiogram (TOE) ruled out vegetations but again illustrated the apical filling defect despite absence of wall motion abnormalities (Fig 2). Finally, a cardiac MRI was arranged and this confirmed the diagnosis of Loeffler’s endocarditis with endomyocardial fibrosis and superimposed LV thrombus (Fig 3). She was treated with anticoagulation and steroids and her eosinophil count normalised before discharge. She remains well with no recurrence at two months post-event. DISCUSSION The diagnosis of Loeffler’s endocarditis depends on the presence high eosinophil count in combination with cardiac involvement on imaging. Transthoracic echocardiography can provide useful information such as apical thickening and thrombus in the left ventricle. As in our case, contrast TTE often provides further detail however contrast-enhanced cardiac MRI remains a key tool in the diagnosis and monitoring of this condition. It provides an assessment of systolic and diastolic function, tissue characterisation and typical features notably endomyocardial fibrosis and thrombosis on late enhancement imaging. CONCLUSIONS We presented a case where cardiac imaging has revealed the diagnosis in a patient presenting with systemic symptoms. We encourage clinicians to use multi-modality cardiac imaging as this has an invaluable role in the diagnostic process of complex patients. Abstract P731 Figure.

P2114Left ventricular myocardial fibrosis measured by contrast-enhanced cardiac MRI as a marker of adverse events in patients with nonischemic ventricular arrhythmias

P2114Left ventricular myocardial fibrosis measured by contrast-enhanced cardiac MRI as a marker of adverse events in patients with nonischemic ventricular arrhythmias