Contrast-enhanced Cardiovascular Magnetic Resonance Research Articles

Nonischemic or Dual Cardiomyopathy in Patients With Coronary Artery Disease.

Randomized trials in obstructive coronary artery disease (CAD) have largely shown no prognostic benefit from coronary revascularization. Although there are several potential reasons for the lack of benefit, an underexplored possible reason is the presence of coincidental nonischemic cardiomyopathy (NICM). We investigated the prevalence and prognostic significance of NICM in patients with CAD (CAD-NICM). We conducted a registry study of consecutive patients with obstructive CAD on coronary angiography who underwent contrast-enhanced cardiovascular magnetic resonance imaging for the assessment of ventricular function and scar at 4 hospitals from 2004 to 2020. We identified the presence and cause of cardiomyopathy using cardiovascular magnetic resonance imaging and coronary angiography data, blinded to clinical outcomes. The primary outcome was a composite of all-cause death or heart failure hospitalization, and secondary outcomes were all-cause death, heart failure hospitalization, and cardiovascular death. Among 3023 patients (median age, 66 years; 76% men), 18.2% had no cardiomyopathy, 64.8% had ischemic cardiomyopathy (CAD+ICM), 9.3% had CAD+NICM, and 7.7% had dual cardiomyopathy (CAD+dualCM), defined as both ICM and NICM. Thus, 16.9% had CAD+NICM or dualCM. During a median follow-up of 4.8 years (interquartile range, 2.9, 7.6), 1116 patients experienced the primary outcome. In Cox multivariable analysis, CAD+NICM or dualCM was independently associated with a higher risk of the primary outcome compared with CAD+ICM (adjusted hazard ratio, 1.23 [95% CI, 1.06-1.43]; P=0.007) after adjustment for potential confounders. The risks of the secondary outcomes of all-cause death and heart failure hospitalization were also higher with CAD+NICM or dualCM (hazard ratio, 1.21 [95% CI, 1.02-1.43]; P=0.032; and hazard ratio, 1.37 [95% CI, 1.11-1.69]; P=0.003, respectively), whereas the risk of cardiovascular death did not differ from that of CAD+ICM (hazard ratio, 1.15 [95% CI, 0.89-1.48]; P=0.28). In patients with CAD referred for clinical cardiovascular magnetic resonance imaging, NICM or dualCM was identified in 1 of every 6 patients and was associated with worse long-term outcomes compared with ICM. In patients with obstructive CAD, coincidental NICM or dualCM may contribute to the lack of prognostic benefit from coronary revascularization.

A distinct septal pattern of late gadolinium enhancement specific for COVID-induced myocarditis: A multicenter cardiovascular magnetic resonance study.

Coronavirus disease-19 (COVID-19) is a great medical challenge provoking acute respiratory distress, pulmonary manifestations, and cardiovascular (CV) consequences. This study compares cardiac injury in COVID-19 myocarditis patients with non-COVID myocarditis patients. Patients who recovered from COVID-19 were scheduled for cardiovascular magnetic resonance (CMR) owing to clinical myocarditis suspicion. The retrospective non-COVID-19 myocarditis (2018-2019) group was enrolled (n=221 patients). All patients underwent a contrast-enhanced CMR, conventional myocarditis protocol, and late gadolinium enhancement (LGE). The COVID study group included 552 patients with a mean (standard deviation [SD]) age 45.9 (12.6) years old. CMR assessment confirmed a myocarditis-like LGE in 46% of the cases (68.5% of the segments with LGE <25% transmural extent), left ventricular (LV) dilatation in 10%, and systolic dysfunction in 16%. The COVID-myocarditis group showed a smaller median (interquartile range [IQR]) LV LGE (4.4% [2.9%-8.1%] vs. 5.9% [4.4%-11.8%]; P <0.001), lower LVEDV (144.6 [125.5-178] ml vs. 162.8 [136.6-194] ml; P <0.001), limited functional consequence (LVEF, 59% [54.1%-65%] vs. 58% [52%-63%]; P = 0.01), and a higher rate of pericarditis (13.6% vs. 6%; P = 0.03) compared to non-COVID myocarditis. The COVID-induced injury was more frequent in septal segments (2, 3, 14), and non-COVID myocarditis showed higher affinity to lateral wall segments (P <0.01). Neither obesity nor age was associated with LV injury or remodeling in subjects with COVID-myocarditis. COVID-19-induced myocarditis is associated with minor LV injury with a significantly more frequent septal pattern and a higher pericarditis rate than non-COVID-19 myocarditis.

Long-term outcomes after coronary artery bypass graft with or without surgical ventricular reconstruction in patients with severe left ventricular dysfunction.

Patients with chronic myocardial infarction (MI) and severe left ventricular (LV) dysfunction have poor clinical outcomes. This study aimed to determine whether coronary artery bypass graft (CABG) with surgical ventricular reconstruction (SVR) leads to further improvement in long-term patient outcomes compared with isolated CABG (I-CABG). From April 2010 to June 2013, 140 consecutive patients with chronic MI and severe LV dysfunction who received contrast-enhanced cardiovascular magnetic resonance imaging (CE-CMR) within 1 month before surgery were enrolled in this study. The cardiovascular events (CVEs) and long-term survival of patients who underwent CABG and SVR were compared with those who met the criteria for SVR but received I-CABG. A total of 140 patients were included in the final analysis, including 70 patients who underwent CABG and SVR and 70 patients who underwent I-CABG. No differences were observed in the baseline characteristics, LV function, and late gadolinium enhancement (LGE) between the two groups. CABG+SVR patients experienced a longer cardiopulmonary bypass (CPB) time (116.0±35.0 vs. 100.2±23.8 minutes, P=0.002) and ventilation time [median (interquartile range): 22.0 (17.0, 37.0) vs. 20.0 (15.0, 24.0) hours, P=0.019] than I-CABG patients. During a mean follow-up of 123.1±12.7 months (range, 102-140 months), the CABG+SVR group had fewer rehospitalizations for congestive heart failure (CHF) (4.3% vs. 19.1%, P=0.007), but no statistical difference in the mortality rate was observed (2.9% vs. 4.4%, P=0.987). The cumulative CVE-free survival rate was significantly higher in CABG+SVR patients (87.0% vs. 67.6%, P=0.007). Our findings indicated that patients with chronic MI and severe LV dysfunction experienced similar perioperative outcomes after CABG+SVR or I-CABG. However, the CABG+SVR group resulted in fewer rehospitalizations for CHF and a higher cumulative CVE-free survival rate.

Cardiac involvement in patients 1 year after recovery from moderate and severe COVID-19 infections.

Some patients suffered persistent cardiac symptoms after hospital discharge following COVID-19 infection, including chest tightness, chest pain, and palpitation. However, the cardiac involvement in these patients remains unknown. The purpose of this study was to investigate the effect of COVID-19 infection on the cardiovascular system after 1 year of recovery in patients hospitalized with persistent cardiac symptoms. In this prospective observational study, a total of 32 patients who had COVID-19 (11 diagnosed as severe COVID-19 and 21 as moderate) with persistent cardiac symptoms after hospital discharge were enrolled. Contrast-enhanced cardiovascular magnetic resonance (CMR) imaging was performed on all patients. Comparisons were made with age- and sex-matched healthy controls (n = 13), and age-, sex- and risk factor-matched controls (n = 21). Further analysis was made between the severe and moderate COVID-19 cohorts. The mean time interval between acute COVID-19 infection and CMR was 462 ± 18 days. Patients recovered from COVID-19 had reduced left ventricular ejection fraction (LVEF) (p = 0.003) and increased extracellular volumes (ECVs) (p = 0.023) compared with healthy controls. Focal late gadolinium enhancement (LGE) was found in 22 (68.8%) patients, mainly distributed linearly in the septal mid-wall or patchily in RV insertion point. The LGE extent in patients with severe COVID-19 was higher than that in patients with moderate COVID-19 (p = 0.009). This 1-year follow-up study revealed that patients with persistent cardiac symptoms, after recovering from COVID-19, had decreased cardiac function and increased ECV compared with healthy controls. Patients with COVID-19 predominately had a LGE pattern of septal mid-wall or RV insertion point. Patients with severe COVID-19 had greater LGE extent than patients with moderate COVID-19.

Diagnostic value of cardiovascular magnetic resonance in acute peripartum cardiomyopathy (PPCM)

Abstract Introduction Peripartum cardiomyopathy (PPCM) is characterised by left ventricular (LV) dilatation and systolic dysfunction developing towards the end of pregnancy or in the first five months postpartum. Cardiovascular magnetic resonance (CMR) allows for comprehensive evaluation of myocardial structure, function, and tissue characteristics. There is a dearth of studies investigating utility of CMR in PPCM. Purpose To evaluate diagnostic benefit of multiparametric assessment of myocardial oedema, fibrotic burden, and strain impairment in PPCM using CMR. Methods Eighteen consenting women with newly diagnosed PPCM and 20 female, age-matched healthy controls (HCs) underwent CMR imaging on a 3T MR scanner. A comprehensive, contrast-enhanced CMR protocol was used including cines, native T1 and T2 mapping, myocardial strain analysis, and extracellular volume (ECV). Images were evaluated qualitatively and semi-quantitively for the presence of late gadolinium enhancement (LGE) Results Patients with PPCM (median age of 34.5 years [IQR 25–38]) presented with severely impaired LV ejection fraction (LVEF) of 31.4% (IQR 19.6–37.9) and reduced right ventricular (RV) ejection fraction (RVEF) of 37.2% (IQR 21.6–51.7). Global longitudinal strain (GLS) was significantly reduced in PPCM patients (−8.9% [IQR −10.8 to −5.6] vs. −19.7 [−21.9 to −16.3], p&amp;lt;0.001) compared to HCs. LGE was present in 13 (81.2%) PPCM patients and included linear or circumferential mid-wall, patchy and diffuse patterns (LGE mass 19.1g [IQR 15.0–26.5] vs. 11.4g [8.8–13.2] in HCs, p&amp;lt;0.001). Patients with PPCM had significantly higher T1 times (1369.3ms [IQR 1343.7–1409.7 vs. 1207.8ms [IQR 1194.8–1241.3], p&amp;lt;0.001) and ECV (36.5% [32.7–37.0] vs. 27.5 [26.3–28.5], p&amp;lt;0.001) compared to HCs. ECV, native T1 and T2 times did not differ between PPCM patients presenting with LVEF ≤35% and &amp;gt;35%. RV dysfunction (present in 61.1% of PPCM cohort) was associated with significantly higher ECV (37.0% [IQR 36.5–38.4] vs 33.4% [IQR 28.5–37.0], p=0.05 and higher T1 (1409.0ms [IQR 1349.0–1443.0] vs. 1311.3ms [IQR 1299.3–1369.3], p=0.015) compared to those with preserved RV function. LV fibrosis was not significantly different between PPCM patients with and without RV dysfunction. LGE mass correlated negatively with LVEF and RVEF (r=−0.540, p=0.001; r=−0.568, p&amp;lt;0.001), respectively. There was a strong positive correlation between LGE mass and native T1 (r=0.619, p&amp;lt;0.001), LGE mass and GLS (r=0.638, p&amp;lt;0.001) and moderate correlation with ECV (r=0.528, p=0.001) (Figure 1). Small, sub-centimetre pericardial effusions were noted in 83.3% of PPCM patients vs. 10% in HCs (p&amp;lt;0.001). Conclusion For the first time, we report a high prevalence of myocardial fibrosis in well-phenotyped patients with newly diagnosed PPCM. Increased LGE mass was associated with severe impairments in LV strain, LVEF and RVEF. RV dysfunction was associated with significantly higher ECV and native T1 times. Funding Acknowledgement Type of funding sources: None.

Prevalence and clinical impact of major incidental findings detected on routine cardiovascular resonance imaging prior to catheter ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Preprocedural contrast-enhanced cardiovascular magnetic resonance (CMR) or computed tomography (CT) imaging of the left atrium (LA) and pulmonary veins (PVs) is usually employed to facilitate catheter mapping and ablation of atrial fibrillation (AF). Incidental findings (IFs) are common on cardiac imaging prior to AF catheter ablation (AFCA). However, previous studies were of small size and have mainly focused on radiological extracardiac IFs detected on preprocedural CT scan. Purpose To assess the prevalence of major cardiac and extracardiac IFs on routine preprocedural CMR in a large cohort of consecutive patients scheduled for first-time AFCA, and to report its impact on clinical decision-making and management. Methods All consecutive patients who underwent routine preprocedural CMR prior to first-time AFCA between April 2015 and March 2019 were considered for analysis. Main exclusion criteria were referral for repeat AFCA; prior cardiac CT or CMR imaging; and general contraindication to CMR or AFCA. All CMR examinations consisted of survey images with full thoracic coverage, cardiac cine and late-gadolinium enhancement imaging, and three-dimensional contrast-enhanced CMR angiography of the LA/PVs. An IF was defined as major when any newly detected finding either resulted in cancellation of the AFCA procedure or intentional deviation from the standard AFCA protocol. In patients with accessory or anomalous PVs the ablation strategy was individually tailored aiming at isolation of all PVs. Results Two thousand consecutive patients (62±10 years; 59% male) with paroxysmal (48%) or persistent (52%) AF were included. Among the entire study cohort 172 patients (8.6%) had a total of 184 cardiac (75%) and extracardiac (25%) major IFs (Fig. A+B). Preprocedural detection of a major IF resulted in cancellation of the scheduled AFCA procedure in 88 patients (4.4%). Forty-two patients (2.1%) have thereupon never been ablated, 46 patients (2.3%) underwent postponed AFCA after a median time from CMR imaging of 83 (32-213) days. The remaining 84 patients with major IF (4.2%) underwent an individualized approach to AFCA (Fig. A). The most common major IFs were accessory or anomalous PVs in 76 (3.8%), extracardiac abnormalities suspicious of malignancy in 29 (1.5%), and positive stress perfusion imaging in 19 (1.0% overall; 7.2% of 261 tested) patients. In 19 patients (1.0%) preprocedural CMR detected a previously unknown intracardiac thrombus or structural cardiac disease. Conclusion Unexpected major IFs on routine preprocedural CMR affected clinical decision-making and therapeutic management in 8.6% of patients scheduled for first-time AFCA at our institution. Whether preprocedural CMR imaging may improve safety and outcome of AFCA needs to be addressed in future research.

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.

Imaging Features of Pediatric Left Ventricular Noncompaction Cardiomyopathy in Echocardiography and Cardiovascular Magnetic Resonance.

Background: Left ventricular noncompaction (LVNC) is a distinct cardiomyopathy characterized by the presence of a two-layer myocardium with prominent trabeculation and deep intertrabecular recesses. The diagnosis of LVNC can be challenging because the diagnostic criteria are not uniform. The aim of our study was to evaluate echocardiographic and CMR findings in a group of children with isolated LVNC. Methods: From February 2008 to July 2021, pediatric patients under 18 years of age at the time of diagnosis with echocardiographic evidence of isolated LVNC were prospectively enrolled. The patients underwent echocardiography and contrast-enhanced cardiovascular magnetic resonance (CMR) with late gadolinium enhancement to assess myocardial noncompaction, ventricular size, and function. Results: A total of 34 patients, with a median age of 11.9 years, were recruited. The patients were followed prospectively for a median of 5.1 years. Of the 31 patients who met Jenni’s criteria in echocardiography, CMR was performed on 27 (79%). Further comprehensive analysis was performed in the group of 25 patients who met the echocardiographic and CMR criteria for LVNC. In echocardiography, the median NC/C ratio in systole was 2.60 and in diastole 3.40. In 25 out of 27 children (93%), LVNC was confirmed by CMR, according to Petersen’s criteria, with a median NC/C ratio of 3.27. Conclusions: (1) Echocardiography precisely identifies patients with LVNC. (2) Echocardiography is a good method for monitoring LV systolic function, but CMR is indicated for the precise assessment of LV remodeling and RV size and function, as well as for the detection of myocardial fibrosis.

False lumen rotational flow and aortic stiffness are associated with aortic growth rate in patients with chronic aortic dissection of the descending aorta: a 4D flow cardiovascular magnetic resonance study

BackgroundPatency of the false lumen in chronic aortic dissection (AD) is associated with aortic dilation and long-term aortic events. However, predictors of adverse outcomes in this population are limited. The aim of this study was to evaluate the relationship between aortic growth rate and false lumen flow dynamics and biomechanics in patients with chronic, patent AD.MethodsPatients with a chronic AD with patent false lumen in the descending aorta and no genetic connective tissue disorder underwent an imaging follow-up including a contrast-enhanced 4D flow cardiovascular magnetic resonance (CMR) protocol and two consecutive computed tomography angiograms (CTA) acquired at least 1 year apart. A comprehensive analysis of anatomical features (including thrombus quantification), and false lumen flow dynamics and biomechanics (pulse wave velocity) was performed.ResultsFifty-four consecutive patients with a chronic, patent false lumen in the descending aorta were included (35 surgically-treated type A AD with residual tear and 19 medically-treated type B AD). Median follow-up was 40 months. The in-plane rotational flow, pulse wave velocity and the percentage of thrombus in the false lumen were positively related to aortic growth rate (p = 0.006, 0.017, and 0.037, respectively), whereas wall shear stress showed a trend for a positive association (p = 0.060). These results were found irrespectively of the type of AD.ConclusionsIn patients with chronic AD and patent false lumen of the descending aorta, rotational flow, pulse wave velocity and wall shear stress are positively related to aortic growth rate, and should be implemented in the follow-up algorithm of these patients. Further prospective studies are needed to confirm if the assessment of these parameters helps to identify patients at higher risk of adverse clinical events.

Detection and evaluation of myocardial fibrosis in Eisenmenger syndrome using cardiovascular magnetic resonance late gadolinium enhancement and T1 mapping

BackgroundMyocardial fibrosis is a common pathophysiological process involved in many cardiovascular diseases. However, limited prior studies suggested no association between focal myocardial fibrosis detected by cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) and disease severity in Eisenmenger syndrome (ES). This study aimed to explore potential associations between myocardial fibrosis evaluated by the CMR LGE and T1 mapping and risk stratification profiles including exercise tolerance, serum biomarkers, hemodynamics, and right ventricular (RV) function in these patients.MethodsForty-five adults with ES and 30 healthy subjects were included. All subjects underwent a contrast-enhanced 3T CMR. Focal replacement fibrosis was visualized on LGE images. The locations of LGE were recorded. After excluding LGE in ventricular insertion point (VIP), ES patients were divided into myocardial LGE-positive (LGE+) and LGE-negative (LGE−) subgroups. Regions of interest in the septal myocardium were manually contoured in the T1 mapping images to determine the diffuse myocardial fibrosis. The relationships between myocardial fibrosis and 6-min walk test (6MWT), N-terminal pro-brain natriuretic peptide (NT-pro BNP), hematocrit, mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance index (PVRI), RV/left ventricular end-systolic volume (RV/LV ESV), RV ejection fraction (RVEF), and risk stratification were analyzed.ResultsMyocardial LGE (excluding VIP) was common in ES (16/45, 35.6%), and often located in the septum (12/45, 26.7%). The clinical characteristics, hemodynamics, CMR morphology and function, and extracellular volume fraction (ECV) were similar in the LGE+ and LGE− groups (all P > 0.05). ECV was significantly higher in ES patients (28.6 ± 5.9% vs. 25.6 ± 2.2%, P < 0.05) and those with LGE− ES (28.3 ± 5.9% vs. 25.6 ± 2.2%, P < 0.05) than healthy controls. We found significant correlations between ECV and log NT-pro BNP, hematocrit, mPAP, PVRI, RV/LV ESV, and RVEF (all P < 0.05), and correlations trends between ECV and 6MWT (P = 0.06) in ES patients. An ECV threshold of 29.0% performed well in differentiating patients with high-risk ES from those with intermediate or low risk (area under curve 0.857, P < 0.001).ConclusionsMyocardial fibrosis is a common feature of ES. ECV may serve as an important imaging marker for ES disease severity.

196 Cardiovascular magnetic resonance characterization of myocardial injury in recovered COVID-19 patients with elevated troponins during hospital stay

AimsDespite being a common finding in hospitalized COVID-19 patients, cardiac troponin elevation remains a nonspecific detection of myocardial injury and further in-hospital investigation into the cause of myocardial injury is rarely done. COVID-19 patients with myocardial injury show a significantly higher in-hospital mortality rate compared with those without myocardial injury and among those with myocardial injury, greater degrees of troponin elevation are associated with higher mortality rates. There are still many questions regarding possible cardiovascular sequelae and prognostic significance in these patients. Being able to distinguish between inflammatory and ischaemic causes of myocardial injury cardiovascular magnetic resonance (CMR) is the non-invasive modality of choice to investigate myocardial involvement in these patients. Presented are the preliminary single-centre results from a multicentre study aimed to characterize the prevalence, type and extent of COVID-19-related cardiovascular sequelae using CMR imaging.Methods and resultsIn this single-centre prospective observational cohort study, patients hospitalized with confirmed COVID-19 and at least one value of high sensitivity I troponin (hs-Tnl) >99th percentile during hospitalization were eligible for follow-up contrast-enhanced CMR imaging. Patients with any standard CMR contraindications were excluded. Images were acquired using a standardized myocarditis protocol including late gadolinium enhancement (LGE) and T1 and T2 mapping. Cutoff values of 1015 ms and 50 ms were used for abnormal T1 and T2 measurements, respectively. Of the 21 patients (65 ± 11.85 years) who underwent imaging, 15 (71.4%) were male. The mean follow-up duration from the date of confirmed COVID-19 diagnosis was 169 ± 19 days. The mean left ventricular ejection fraction was 64.1 ± 13.87 and 3 (14.3%) patients had evidence of wall motion abnormalities. LGE was seen in 9/20 (45.0%) patients, reflecting myocardial fibrosis. Increased native T1 signal representing myocardial fibrosis and/or oedema was seen in 9/20 (45.0%) patients. While increased native T2 signal, being more specific for oedema was observed in 3/20 (15.0%) patients. Considering CMR findings, 6 (28.6%) patients showed evidence of previous myocarditis.ConclusionsIn this single centre Italian study of patients hospitalized with COVID-19 and elevated cardiac enzymes, myocarditis-like injury was evident in about a quarter of the patients. Whether these findings will lead to long-term cardiac complications is still to be confirmed.

Left ventricular involvement assessed by LGE-CMR in predicting the risk of adverse outcomes of arrhythmogenic cardiomyopathy with ICDs

BackgroundArrhythmogenic cardiomyopathy (ACM) is characterized by a high incidence of ventricular tachyarrhythmia and sudden death. Implantable cardioverter-defibrillator (ICD) implantation is the cornerstone of management. ObjectiveThis study aims to reveal the prognostic value of the contrast-enhanced cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) amount in predicting varying lethal outcomes among ACM patients with ICDs. MethodsThe 88 patients with definite ACM who were all referred for contrast-enhanced CMR received an ICD and were followed up for a median of 4.0 years. ResultsFifty-four patients had no left ventricular (LV) involvement and sixteen had an LV LGE amount > 15%. During the follow-up time, appropriate ICD therapy was seen in 57, electrical storm (ES) in 19, and cardiac death in 9 patients. Compared with those without LV involvement, patients with LV LGE amount > 15% had a higher risk of cardiac death (log-rank P = 0.021). LV LGE amount was associated with an increased risk of ICD therapy [adjusted hazard ratio (HR) 1.035, 95% confidence interval (CI) 1.008–1.062, P = 0.010], and cardiac death (adjusted HR 1.082, 95% 1.006–1.164, P = 0.034), independently of LV ejection fraction. LV LGE mass of >15% demonstrated an over 2-fold increase in ICD therapy (adjusted HR 2.180, 95%CI 1.058–4.488, P = 0.035) and an over 7-fold increase in cardiac death (unadjusted HR 7.198, 95%CI 1.399–37.043, P = 0.018) than those without LV involvement, respectively. ConclusionsThe LV LGE-CMR in ACM shows a dose-dependent association with ICD therapy and cardiac death. And LV LGE amount of >15% is a strong predictor.

Myocardial motion-corrected phase-sensitive inversion recovery late gadolinium enhancement in free breathing paediatric patients: a comparison with single-shot coherent gradient echo (“TrueFISP”) phase-sensitive inversion recovery

To investigate the value of motion-corrected (MOCO) phase-sensitive inversion recovery (PSIR) late gadolinium enhancement (LGE) compared with single-shot balanced steady-state gradient echo ("TrueFISP", Siemens) PSIR in free breathing paediatric patients. In this retrospective study, 238 paediatric patients underwent clinical contrast-enhanced cardiovascular magnetic resonance imaging (CMRI). Both the single-shot TrueFISP PSIR and MOCO PSIR sequences were performed on each child. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Two radiologists rated the quality of the images on a scale of 1-5 (1=poor, 5=very good). Bland-Altman, linear regression, and intraclass correlation coefficient were used to compared the extent of LGE of the single-shot TrueFISP PSIR and MOCO PSIR. Imaging artefacts were described and compared. Children ranged in age from 60 days to 17 years with an average age of 8.1±3.8 years. MOCO PSIR had higher SNR and CNR than the single-shot TrueFISP PSIR (p<0.001). Mean quality ratings for short-axis imaging were 4 (interquartile range, 3-4) for single-shot TrueFISP PSIR and 4 (interquartile range, 4-5) for MOCO PSIR (p<0.001). The scan time was faster for single-shot TrueFISP PSIR than for MOCO PSIR. The myocardial LGE results were similar with high agreement between the single-shot TrueFISP PSIR and MOCO PSIR (ICC=0.955-0.986). The MOCO PSIR sequence is feasible in children. MOCO PSIR is robust at high heart rates and can be performed without breath-holding with higher image-quality ratings than the single-shot TrueFISP PSIR.

False lumen pressure estimation in type B aortic dissection using 4D flow cardiovascular magnetic resonance: comparisons with aortic growth

BackgroundChronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax).MethodsCMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either ‘stable’ (< 3 mm/year) or ‘enlarging’ (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL.ResultsFLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = − 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter.ConclusionComparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

Predictive values of multiple non-invasive markers for myocardial fibrosis in hypertrophic cardiomyopathy patients with preserved ejection fraction

Myocardial fibrosis assessed by late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) is associated with cardiovascular outcomes in hypertrophic cardiomyopathy (HCM) patients, but little is known about the utility of non-invasive markers for detecting LGE. This study aims to explore the association between cardiac-specific biomarkers, CMR myocardial strain, left ventricular (LV) hypertrophy and LGE in HCM patients with preserved ejection fraction (EF) and investigate the predictive values of these indexes for LGE. We recruited 33 healthy volunteers and 86 HCM patients with preserved EF to undergo contrast-enhanced CMR examinations. In total, 48 of 86 HCM patients had the presence of LGE. The LGE-positive patients had significant higher serum high-sensitivity cardiac troponin I (hs-cTnI) and N-terminal pro b-type natriuretic peptide (Nt-proBNP) levels and lower global longitudinal (GLS) and circumferential (GCS) strains than the LGE-negative group. The LGE% was independently associated with the Nt-proBNP levels, GCS, LV end-diastolic maximum wall thickness (MWT) and beta-blocker treatment. In the receiver operating characteristic curve analysis, the combined parameters of Nt-proBNP ≥ 108.00 pg/mL and MWT ≥ 17.30 mm had good diagnostic performance for LGE, with a specificity of 81.25% and sensitivity of 70.00%. These data indicate that serum Nt-proBNP is a potential biomarker associated with LGE% and, combined with MWT, were useful for identifying myocardial fibrosis in HCM patients with preserved EF. Additionally, LV GCS may be a more sensitive indicator for reflecting the presence of myocardial fibrosis than GLS.

Interatrial septal aneurysm mimicking an atrial myxoma on multiparametric cardiovascular magnetic resonance imaging

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Interatrial septal aneurysm (IASA) appears as a localised saccular deformity usually detected during routine echocardiography or stroke evaluation. Imaging hallmarks are &amp;gt;15mm prolapsing motion across the interatrial septum (IAS) and identical content to blood-pool, which are in contrast to this patient. Clinical case An 81-year-old asymptomatic man underwent transesophageal echocardiographic (TEE) right atrial mass assessment revealing a well-circumscribed, mobile mass attached to the interatrial septum suggestive of myxoma. Given previously-excised renal cell carcinoma, gadolinium contrast-enhanced cardiovascular magnetic resonance (CMR) imaging was performed for mass characterisation. Mass signal intensity (SI) was distinct to blood-pool, in keeping with mass content not being blood. Cine imaging revealed an isointense, mobile mass (Figure 1, Video 1) attached to the fossa ovalis. The mass was of intermediate SI isointense to myocardium on T1-weighted, and bright and hyperintense on T2-weighted imaging. First-pass perfusion (Video 2) and early enhancement imaging demonstrated a hypointense, non-perfusing mass. The mass hyperenhanced on late enhancement imaging excluding the differential of thrombus. Imaging findings were entirely consistent with atrial myxoma. Intraoperatively, the excised mass was actually confirmed as an IASA with exquisitely tight neck. Discussion This is the first case of IASA mimicking atrial myxoma on CMR imaging. We postulate that it behaved like a non-perfusing mass as its uniquely narrow neck resulted in extremely slow flow in and out. This permitted minimal blood with contrast entry which remained ‘trapped’ within, resulting in distinct SI to blood pool, and late hyperenhancement. Left atrial pressures forced the mass into the right atrium, preventing typical lateral IASA motion. Conclusion The diagnosis of IASA is best established with TEE while CMR imaging is the reference standard imaging modality for tissue characterization. It is vital to be able to identify and differentiate such entities to avoid misdiagnosis of an IASA as a cardiac myxoma or a malignant cardiac tumour. Nevertheless, we recognize the presence of limitation of imaging in this extraordinary case. Abstract Figure 1

Risk Stratification Guided by the Index of Microcirculatory Resistance and Left Ventricular End-Diastolic Pressure in Acute Myocardial Infarction.

The index of microcirculatory resistance (IMR) of the infarct-related artery and left ventricular end-diastolic pressure (LVEDP) are acute, prognostic biomarkers in patients undergoing primary percutaneous coronary intervention. The clinical significance of IMR and LVEDP in combination is unknown. IMR and LVEDP were prospectively measured in a prespecified substudy of the T-TIME clinical trial (Trial of Low Dose Adjunctive Alteplase During Primary PCI). IMR was measured using a pressure- and temperature-sensing guidewire following percutaneous coronary intervention. Prognostically established thresholds for IMR (>32) and LVEDP (>18 mm Hg) were predefined. Contrast-enhanced cardiovascular magnetic resonance imaging (1.5 Tesla) was acquired 2 to 7 days and 3 months postmyocardial infarction. The primary end point was major adverse cardiac events, defined as cardiac death/nonfatal myocardial infarction/heart failure hospitalization at 1 year. IMR and LVEDP were both measured in 131 patients (mean age 59±10.7 years, 103 [78.6%] male, 48 [36.6%] with anterior myocardial infarction). The median IMR was 29 (interquartile range, 17-55), the median LVEDP was 17 mm Hg (interquartile range, 12-21), and the correlation between them was not statistically significant (r=0.15; P=0.087). Fifty-three patients (40%) had low IMR (≤32) and low LVEDP (≤18), 18 (14%) had low IMR and high LVEDP, 31 (24%) had high IMR and low LVEDP, while 29 (22%) had high IMR and high LVEDP. Infarct size (% LV mass), LV ejection fraction, final myocardial perfusion grade ≤1, TIMI (Thrombolysis In Myocardial Infarction) flow grade ≤2, and coronary flow reserve were associated with LVEDP/IMR group, as was hospitalization for heart failure (n=18 events; P=0.045) and major adverse cardiac events (n=21 events; P=0.051). LVEDP>18 and IMR>32 combined was associated with major adverse cardiac events, independent of age, estimated glomerular filtration rate, and infarct-related artery (odds ratio, 5.80 [95% CI, 1.60-21.22] P=0.008). The net reclassification improvement for detecting major adverse cardiac events was 50.6% (95% CI, 2.7-98.2; P=0.033) when LVEDP>18 was added to IMR>32. IMR and LVEDP in combination have incremental value for risk stratification following primary percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02257294.

Cardiac magnetic resonance imaging for the detection of myocardial involvement in granulomatosis with polyangiitis

The prevalence of undiagnosed cardiac involvement in granulomatosis with polyangiitis (GPA) is unknown. In this prospective study we investigated the utility of cardiovascular magnetic resonance (CMR) to identify myocardial abnormalities in GPA and their correlation with disease phenotype. Twenty-six patients with GPA and no cardiovascular disease or diabetes mellitus underwent contrast-enhanced CMR, including late gadolinium-enhancement (LGE), T1-mapping for native T1 and extra-cellular volume (ECV) quantification for assessment of myocardial fibrosis, cine imaging and tissue tagging for assessment of left ventricular (LV) function. Twenty-five healthy volunteers (HV) with comparable age, sex, BMI and arterial blood pressure served as controls. Patients with GPA had similar cardiovascular risk profile to HV. A focal, non-ischaemic LGE pattern of fibrosis was detected in 24% of patients and no controls (p = 0.010). Patients with myocardial LGE were less frequently PR3 ANCA (7% vs 93%, p = 0.007), and had involvement of the lower respiratory tract and skin. LGE scar mass was higher in patients presenting with renal involvement. Native T1 and ECV were higher in patients with GPA than HV; ECV was higher in those with relapsing disease, and native T1 was inversely associated with PR3 ANCA (β = − 0.664, p = 0.001). Peak systolic strain was slightly reduced in GPA compared to controls; LV ejection function was inversely correlated with disease duration (β = − 0.454, p = 0.026). Patients with GPA have significant myocardial abnormalities on CMR. ANCA, systemic involvement and disease severity were associated with myocardial fibrosis. CMR could be a useful tool for risk stratification of myocardial involvement in GPA.

A direct comparison of 3\u2009T contrast-enhanced whole-heart coronary cardiovascular magnetic resonance angiography to dual-source computed tomography angiography for detection of coronary artery stenosis: a single-center experience

BackgroundIn recent years, substantial advances have been made in noninvasive cardiac imaging, including cardiac computed tomography (CT) and cardiovascular magnetic resonance (CMR). The purpose of this study was to prospectively compare the diagnostic performance of contrast-enhanced whole heart coronary CMR angiography (CCMRA) to dual-source coronary CT angiography (CCTA) for the diagnosis of significant coronary stenoses (≥50%) in patients with known or suspected coronary artery disease (CAD) referred for conventional x-ray coronary angiography.MethodsOur objective was to directly compare the diagnostic accuracy of contrast-enhanced whole-heart CCMRA (CE-CCMRA) to dual-source CCTA (DS-CCTA) for the detection of CAD. We prospectively studied 57 symptomatic patients with suspected or known CAD who were scheduled for conventional x-ray coronary angiography. Significant CAD was defined as an x-ray defined diameter reduction of ≥50% in a coronary artery with a reference diameter of ≥1.5 mm.ResultsCE-CCMRA and DS-CCTA were completed in 51 (89%) of 57 patients without complications. The acquisition times of CE-CCMRA and DS-CCTA, respectively, were 9.5 ± 3.1 min and 8.3 ± 1.4 s. On patient-based analysis, the sensitivity, specificity, positive and negative predictive value of CE-CCMRA and DS-CCTA were 93.5% versus 93.5%(P > 0.05), 85% versus 90%(P > 0.05), 90.6% versus 93.5%(P > 0.05), and 89.4% versus 90%(P > 0.05), respectively. The area under the curve (AUC) was 0.89 (95% CI: 0.79 to 0.99) for CE-CCMRA and 0.92 (95% CI: 0.83 to 1.00) for DS-CCTA.ConclusionsDS-CCTA was found to be superior to CE-CCMRA in the diagnosis of significant coronary stenoses (≥50%) in patients with suspected or known CAD scheduled for conventional x-ray coronary angiography, owing to shorter scanning times and higher spatial resolution. However, CE-CCMRA and DS-CCTA have similar diagnostic accuracies.

P177 Left atrial strain in patients with cardiac amyloidosis. Relationship to left atrial amyloid deposition focusing on prognosis

Abstract Background In cardiac amyloidosis (CA), the left atrium (LA) is frequently infiltrated by the amyloid fibrils. It is currently known that LA strain is a marker of LA function and prognosis in many cardiac diseases, however its significance in CA remains unknown. Purpose Our aim was to investigate correlation between LA strain measured by Cardiovascular Magnetic Resonance (CMR) and amyloid deposit in LA, and also evaluate the LA strain on the prognostic significance. Methods and results Of 74 consecutive patients with biopsy-proven CA, we analyzed 42 patients (age 72 ± 10 years; 76 % males) with contrast-enhanced CMR, and examined LA late gadolinium enhancement (LGE) and CMR derived LA strain using feature tracking method. Of the 42 patients, 29 patients (69 %) was transthyretin cardiac amyloidosis (ATTR-CA) in the majority. We divided these 42 patients into two groups according to the CMR measured peak atrial longitudinal strain (PALS) (&amp;gt; = or &amp;lt; median); high-strain (&amp;gt; = 6.67 %, n = 21) and low-strain (＜ 6.67 %, n = 21) and compared the patient’s characteristics, blood test data, echocardiography and CMR parameters. There were no significant differences between two groups in these parameters but in the extent of LA-LGE (54 % vs 80 %, p = 0.008). The PALS correlated with the extent of LA-LGE (ρ= 0.50, p = 0.001). In multivariate analysis including LVEF, E/e’ and BNP, LA-LGE was an independent determinant of PALS. During three-year follow up, the LA strain significantly related to heart failure hospitalization in the ATTR-CA patients (p = 0.036)(Figure). Conclusions In CA patients, CMR measured LA longitudinal strain correlates with the LA-LGE. It also provides useful information for poor prognosis of patients with ATTR-CA. Abstract P177 Figure. Heart failure hospitalization in ATTR-CA