Elevated T2 Research Articles

Positive Progesterone Receptor Expression in Meningioma May Increase the Transverse Relaxation: First Prospective Clinical Trial Using Single-Shot Ultrafast T2 Mapping

Rationale and ObjectivesThis project aims to investigate the diagnostic performance of multiple overlapping-echo detachment imaging (MOLED) technique-derived transverse relaxation time (T2) maps in predicting progesterone receptor (PR) and S100 expression in meningiomas. Materials and Methods63 meningioma patients were enrolled from October 2021 to August 2022, who underwent a complete routine magnetic resonance imaging and T2 MOLED, which can characterize the whole brain transverse relaxation time within 32 seconds in a single scan. After the surgical resection of meningiomas, the expression levels of PR and S100 were determined by an experienced pathologist using immunohistochemistry techniques. Histogram analysis was performed in tumor parenchyma based on the parametric maps. Independent t test and Mann-Whitney U test were applied for the comparison of histogram parameters between different groups, with a significance level of P < .05. Logistic regression and receiver operating characteristic (ROC) analysis with 95% confidence interval were conducted for the diagnostic efficiency evaluation. ResultsPR-positive group had significantly elevated T2 histogram parameters (P = .001-.049) compared to the PR-negative group. The multivariate logistic regression model with T2 showed the highest area under the ROC curve (AUC) for predicting PR expression (AUC=0.818). Additionally, the multivariate model also had the best diagnostic performance for predicting meningioma S100 expression (AUC=0.768). ConclusionThe MOLED technique-derived T2 maps can distinguish PR and S100 status in meningiomas preoperatively.

A changing heart in tako-tsubo syndrome.

A 63-year-old female presented with acute chest pain and ECG showing T wave inversion in the anterior and inferior leads. Troponin T (TnT) was significantly elevated (peak 1378 ng/L; normal <14 ng/L), as was NT-proBNP (3091 ng/L; normal <400 ng/L). Invasive angiography showed unobstructed coronary arteries with mid-ventricular ballooning and hypokinesia on ventriculography (see Supplementary data online, Video S1) and echocardiography (see Supplementary data online, Video S2), suggesting a mid-ventricular tako-tsubo syndrome (TTS). Cardiac magnetic resonance (CMR) was booked but the patient was unable to attend. Focussed history using the InterTAK diagnostic score assessment revealed no emotional or physical triggers. The patient re-presented six months later with similar symptoms and elevated TnT. Inpatient echocardiography showed a reverse TTS pattern (see Supplementary data online, Video S3) and CMR at 1.5T showed basal hypokinesia with matching elevated native T1 (1220 ms; normal 950–1100 ms) and T2 (69 ms; normal <48 ms) (Panels A–B). Quantitative perfusion maps following adenosine stress perfusion to investigate microvascular disease showed basal to mid circumferential hypoperfusion with normal apical myocardial blood flow, not suggestive of specific coronary artery territory ischaemia (Panel D) and no late gadolinium enhancement (LGE) (Panel C), confirming a reverse TTS. The patient further presented two months later with chest pain and TnT elevation. Repeat inpatient CMR on this occasion showed a classic TTS pattern with apical hypokinesia and elevated T1 and T2 (1261 ms and 81 ms, respectively) at the mid to apical segments with no LGE (Panels E–G). The case was further explored but no triggers, including neurological or psychiatric abnormalities were found. Recurrent TTS with different phenotypes has previously been described but is rare, especially without a trigger. Our case illustrates the utility of multimodality imaging in the investigation of TTS; in particular, multiparametric tissue mapping by CMR. Furthermore, the novel quantitative perfusion maps characterising myocardial blood flow added diagnostic utility.

C62 CHALLENGING DIAGNOSIS OF A TRIPLE CARDIAC PATHOLOGY: TRANSTHYRETIN AMYLOIDOSIS WITH ASPECTS OF HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY AND ANOMALOUS CORONARY ARTERY

Abstract A 70 years–old man with a history of systemic hypertension and surgically treated bilateral carpal tunnel was referred for dyspnea on exertion for few months. At physical examination a systolic heart murmur exacerbated by Valsalva maneuver was appreciated; no signs of heart failure. EKG with low–voltage QRS is shown in Fig.1A. Blood tests showed elevated NT–proBNP (1434 pg/ml). Transthoracic echo (ETT) revealed hyperdynamic left ventricle (LV) with severe asymmetric hypertrophy (interventricular septum 23 mm, posterior wall 17 mm), ‘granular sparkling’ appearance of myocardium, grade 2 diastolic dysfunction and ‘apical sparing’ pattern at global longitudinal strain (GLS, Fig.1B). Moreover, elongated mitral leaflets, anomalies of mitral sub–valvular apparatus with apically displaced papillary muscles and systolic anterior motion of the mitral valve (SAM) with dynamic outflow tract obstruction (20 mmHg at rest and 90–100 mmHg with Valsalva maneuver) were seen (Fig. 2A–B–C). For ETT suspicion of a coronary artery anomaly (Fig.3A), the patient underwent coronary CT angiography that confirmed a separate origin of left anterior descending artery (LAD) from right coronary sinus with a long mid–proximal intramyocardial bridge (Fig.3B–C). As a part of evaluation of the hypertrophic phenotype, a 99mTC–HDP bone scintigraphy was performed with high–grade of cardiac uptake (Perugini Score 2, Fig.1C). Screening for monoclonal gammopathy and genetic testing for hereditary amyloidosis resulted negative. Cardiac MRI revealed late gadolinium enhancement (LGE) in midwall septum, diffuse endocardial LGE in the LV basal inferior and posterolateral walls (Fig.1D), elevated T1 mapping and ECV (40–42%) and confirmed the asymmetric hypertrophy with apically displaced papillary muscles (Fig.2D) and SAM. These clinical, EKG and imaging features led to a non–invasive diagnosis of wild–type transthyretin cardiac amyloidosis (ATTRwt) with aspects of hypertrophic obstructive cardiomyopathy (HOCM). The patient started a disease–modifying therapy with Tafamidis and, cautiously, Metoprolol tartrate, with good tolerance and relevant reduction of LVOT obstruction at follow–up. Genetic testing for HCM was also performed. In conclusion, in rare cases hypertrophic phenotype may be challenging, showing features overlap between ATTR and HOCM. Multimodality evaluation is crucial for a correct diagnosis, thus identifying the most effective target–therapy for the underlying hypertrophic phenotype.

High-resolution diffusion tensor imaging and T2 mapping detect regional changes within the hippocampus in multiple sclerosis.

Hippocampus demyelinating lesions in multiple sclerosis (MS) have been frequently observed in ex vivo histopathological studies; however, they are difficult to image and quantify in vivo. Diffusion tensor imaging (DTI) and T2 mapping could potentially detect such regional in vivo changes if acquired with sufficient spatial resolution. The goal here was to evaluate whether there are focal hippocampal abnormalities in 43 MS patients (35 relapsing-remitting, eight secondary progressive) with and without cognitive impairment (CI) versus 43 controls using high-resolution 1 mm isotropic DTI, as well as complementary methods of T2-weighted and T2 mapping at 3 T. Abnormal hippocampus regions were identified voxel-by-voxel by using mean diffusivity (MD)/T2 thresholds and avoiding voxels attributed to cerebrospinal fluid. When compared with controls, averaged left/right whole hippocampus MD was higher in both MS groups, while lower fractional anisotropy (FA) and volume, and higher T2 relaxometry and T2-weighted signal values, were only significant in CI MS. The hippocampal MD and T2 images/maps were not uniformly affected and focal regions of elevated MD/T2 were evident in MS patients. Both CI and not CI MS groups showed greater proportional areas of the hippocampus with elevated MD, whereas only the CI group showed a greater proportional area of elevated T2 relaxation times or T2-weighted signal. Higher T2 relaxometry and T2-weighted signal values of elevated regions correlated with greater disability and whole hippocampus FA negatively correlated with physical fatigue. High-resolution hippocampus DTI and T2 mapping with less partial volume effects showed whole hippocampus abnormalities with regional elevations of MD/T2 in MS, which could be interpreted as potentially from demyelination, neuron loss, and/or inflammation, and which overall were more extensive in the hippocampus of patients with larger total brain lesion volumes and CI.

Effectiveness of T2 biologics in patients with common variable immune deficiency and allergic respiratory disease

IntroductionMany patients with common variable immune deficiency (CVID) have a history suggestive of allergic respiratory disease including chronic rhinosinusitis (CRS) and asthma. The underlying immunologic defect, the presence of comorbid conditions such as bronchiectasis or interstitial lung disease, and recurrent infections may make the diagnosis of these conditions difficult. T2 biologics targeting allergic inflammatory pathways are now the standard of care for severe persistent asthma and CRS with nasal polyposis (CRSwNP). The efficacy of these agents in patients with CVID is unknown. MethodsWe performed a retrospective analysis of patients with CVID at a single academic medical center and identified those who had ever been prescribed a T2 biologic. ResultsWe identified 8 patients with CVID who had ever been prescribed T2 biologics: 6 patients with severe persistent asthma and 2 patients with CRSwNP. All patients had CVID without inflammatory complications with therapeutic IgG levels on immune globulin replacement therapy. Comorbid bronchiectasis was identified in 3 patients and no patients had GLILD. Two patients were taking omalizumab, two on mepolizumab, 1 on benralizumab, and 1 on dupilumab for severe persistent asthma and 2 on dupilumab for CRSwNP. Only 4 patients in this group (50%) had subjective improvement of symptoms and objective clinical benefit based on ability to wean off of corticosteroids and fewer exacerbations per year. Only 1 of these patients had objective improvement in FEV1 by >200mL. Neither of the 2 patients treated with dupilumab for CRswNP reported improvement and the biologic was discontinued. Of the 2 patients with asthma who were found to have eosinophilia on bronchoalveolar fluid analysis, both of these patients had clinical improvement on eosinophil-targeted biologic therapy. All 3 patients who were tested were found to have elevated serum T2 cytokines including IL-4, but this did not predict response to therapy.Table 1(abstract: 191) Demographic and immunologic data of 8 patients with CVID on T2 biologiesAgeGenderT2 biologicIndicationBronchiectasisIncrease in FEV1 by >200mLClinical responseIgG (mg/dL)IgA (mg/dL)IgM (mg/dL)IgE (kU/L)Absolute eosinophil count(K/μL)CD19B cell count (cells/μL)Th2 Cytokine PanelBAL Eosinophils%CT ThoraxBronchoscopy-Pathology82Fomalizumabsevere persistent asthmayesnono1551522923430049Not availableNot availableBasal abnormalitycharacterized by ground glass opacities (GGO), centrilobular nodularity with small focus of consolidation posterior right lower lobe (RLL). Additional focus of patchy groundglass posterior right lung (RL).Not available74Mmepolizumabsevere persistent asthmayesnoyes11681623141681600176Not available25Resolution of right upper lobe (RUL) apical nodule and branching tubular opacity. New clustered nodularity in the posterior RLL with faint GGO in the upper lobes. Moderate bronchial wall thickening, greatest in the lower lobes.Bronchial wall with smooth muscle hypertrophy. Lung parenchyma without evidence of inflammation, fibrosis, or malignancy.57Fomalizumabsevere persistent asthmanonoyes89725221687100103Not available0Diffuse bronchial dilation without bronchial wall thickening. Mild patchy air trapping.Largely denuded and edematous bronchial wall with minima] chronic inflammation, focal subepithelial elastosis, focal expansion of the subbasal lamina, mild increase in mucous secretion.37Fdupilumabchronic rhinosinusitis with nasal Polyposisnonot applicableno787<10<20<2100187elevated IL-4, IL-6Not availableResolved patchy GGO with exception of a new tiny focus of GGO in the basal RLL. Stable mild diffuse bronchial wall thickening.Not available73Fbenralizumabsevere persistentnoyesyes84635<20<2100179Not available4Mild to moderate airway inflammation and diffuse air-trapping. Minimal left basilar linear atelectasis/scarring is new. TracheobronchomalaciaBronchial wall with moderate chronic inflammation and eosionphils (peak 12/hpf), thickened subbasal lamina, mild smooth muscle hypertrophy.43Fdupilumabsevere persistent asthmanonot availableyes12614313556.5056elevated IL-4, IL-5, IL-6Not availableBenign right oblique fissure. 2 small nodules.Not available56Fdupilumabyesnot applicableno95476602.625027Not available1chronic rhinosinusitis with nasal polyposisMultiple new areas of peribronchovascular consolidation and confluent GGO. Widespread tree-inbud nodularity. Mild cylindricalbronchiectasis. Dilated main pulmonary trunk.Bronchial wall with moderate chronic inflammation and scattered eosinophils (6/hpf), thickened subbasal lamina. No granulomas. Right lung bronchial wall with moderate chronic inflammation. Lung parenchyma with airway centered mild interstitial chronic inflammation49 Fmepolizumabsevere persistent asthmanonono166845189510049Not available0Mild bronchial wall thickening and scattered air trapping. Patchy GGO in the left upper lobe with minimal involvement of the lower lobes. Dynamic expiratory images demonstrates evidence of tracheobronchomalacia.Bronchial wall with patchy mild to moderate chronic inflammation with rare neutrophils and eosinophils. Mild smooth muscle hypertrophy. Patchy squamous metaplasia and respiratory bronchiolitis in the left lung.*Clinical response is measured by reduction in exacerbations and/or ability to wean off of corticosteroids for individuals with severe asthma and is measured by improvement in sinonasal symptoms and reduced nasal polypoid burden for CRSwNP. [Display omitted] [Display omitted] ConclusionPatients with CVID may benefit from more direct sampling of nasal mucosal and bronchial secretions (sputum, bronchoalveolar lavage) to determine the potential benefit from T2 biologics in severe allergic respiratory disease. Prospective analyses in larger cohorts following objective indices of improvement as well as changes in serum and mucosal biomarkers are necessary.

Persistent underloading of patellofemoral joint following hamstring autograft ACL reconstruction is associated with cartilage health

To determine the longitudinal changes of patellofemoral joint (PFJ) contact pressure following anterior cruciate ligament reconstruction (ACLR). To identify the associations between PFJ contact pressure and cartilage health. Forty-nine subjects with hamstring autograft ACLR (27 males; age 28.8 [standard deviation, 8.3] years) and 19 controls (12 males; 30.7 [4.6] years) participated. A sagittal plane musculoskeletal model was used to estimate PFJ contact pressure. A combined T1ρ/T2 magnetic resonance sequence was obtained. Assessments were performed preoperatively, at 6 months, 1, 2, and 3 years postoperatively in ACLR subjects and once for controls. Repeated Analysis of Variance (ANOVA) was used to compare peak PFJ contact pressure between ACLR and contralateral knees, and t-tests to compare with control knees. Statistical parametric mapping was used to evaluate the associations between PFJ contact pressure and cartilage relaxation concurrently and longitudinally. No changes in peak PFJ contact pressure were found within ACLR knees over 3 years (preoperative to 3 years, 0.36 [CI, -0.08, 0.81] MPa), but decreased over time in the contralateral knees (0.75 [0.32, 1.18] MPa). When compared to the controls, ACLR knees exhibited lower PFJ contact pressure at all time points (at baseline, -0.64 [-1.25, -0.03] MPa). Within ACLR knees, lower PFJ contact pressure at 6 months was associated with elevated T2 times (r=-0.47 to -0.49, p=0.021-0.025). Underloading of the PFJ following ACLR persists for up to 3 years and has concurrent and future consequences in cartilage health. The non-surgical knees exhibited normal contact pressure initially but decreased over time achieving limb symmetry.

Low Prevalence of Late Myocardial Injury on Cardiac MRI Following COVID-19 Infection.

The prevalence of abnormal cardiac magnetic resonance imaging (MRI) findings indicative of myocardial injury in patients who recovered from coronavirus disease 2019 (COVID-19) is currently unclear, with a high variability in the reported prevalence. To assess the prevalence of myocardial injury after a COVID-19 infection. Prospective, bicentric study. Seventy consecutive patients who recovered from COVID-19 and were previously hospitalized. Mean age was 57 years and 39% of the patients were female. Ten healthy controls and a comparator group of 75 nonischemic cardiomyopathy (NICM) patients were employed. 1.5-T, steady-state free precession (SSFP) gradient-echo sequence, modified Look-Locker inversion recovery sequence with balanced SSFP readout, T2-prepared spiral readout sequence and a T1-weighted inversion recovery fast gradient-echo sequence was acquired ~4-5 months after recovery from COVID-19. The SSFP sequence was utilized for the calculation of left and right ventricular volumes and ejection fractions (LVEF and RVEF) following manual endocardial contouring. T1 and T2 mapping was performed by pixel-wise exponential fitting, and T1 and T2 values were computed by manual contouring of the left ventricular endocardial and epicardial walls. Late gadolinium enhancement (LGE) images were graded qualitatively as LGE present or absent. T-tests and the χ2 or Fisher's exact tests were used to compare continuous and categorical variables respectively between the COVID-19 and NICM groups. Inter-rater agreement was evaluated by the intraclass correlation coefficient for continuous variables and Cohen's kappa test for LGE. Reduced RVEF occurred in 10%, LGE and elevated native T1 in 9%, reduced LVEF in 4%, and elevated T2 in 3% of COVID-19 patients, respectively. Patients with NICM had lower mean LVEF (41.6% ± 6% vs. 60% ± 7%), RVEF (46% ± 5% vs. 61% ± 9%), and a significantly higher prevalence of LGE (27% vs. 9%) when compared to those post-COVID-19. Abnormal cardiac MRI findings may show a low prevalence in patients who recovered from COVID-19 and were previously hospitalized. 2 TECHNICAL EFFICACY: Stage 2.

Comprehensive cardiac magnetic resonance T1, T2, and extracellular volume mapping to define Duchenne cardiomyopathy

BackgroundCardiomyopathy is the leading cause of death in Duchenne muscular dystrophy (DMD). Cardiac magnetic resonance (CMR) parametric mapping sequences offer insights into disease pathophysiology. We propose a novel approach by leveraging T2 mapping in conjunction with T1 and extracellular volume (ECV) mapping to perform a virtual myocardial biopsy. While previous work has attempted to describe myocardial changes in DMD, our inclusion of T2 mapping enables comprehensive categorization of myocardial tissue characteristics of fibrosis, edema, and fat to better understand the pathological composition of the myocardium with disease progression. MethodsDMD patients (n = 49; median: 12 years-old) underwent CMR, including T1, T2, and ECV. Categories were defined as normal, isolated high T1 (normal ECV, high T1, normal T2), fibrosis (high ECV, normal or high T1, normal T2), edema (normal or high ECV, normal or high T1, high T2), fat (normal ECV, low T1, high T2) or fibrofatty (high ECV, low T1, high T2). ResultsMedian left ventricular ejection fraction (LVEF) was 59% with 27% having LVEF < 55%. Those with normal LVEF and no late gadolinium enhancement (37%) were younger in age (10.5 ± 2.6 vs. 15.0 ± 4.3 years-old, p < 0.001). Native T1 was elevated in at least one slice in 82% of patients. Those with high T2 at any slice (27%) were older (p = 0.005) and had lower LVEF (p = 0.005) compared with subjects with normal T2 (73%). The most common myocardial characterization was fibrosis (43%) followed by isolated high T1 (24%). Of the 13 with high T2, ten were categorized as edema, two as fibrofatty, and one as fat. ConclusionCMR parametric mapping sequences offer insights into Duchenne cardiomyopathy pathophysiology, which should drive development of therapeutic interventions aimed at these targets. Myocardial fibrosis is common in DMD. Patients with elevated T2 were older and had lower LVEF. Though fat infiltration was present, the majority of subjects with elevated T2 met criteria for myocardial edema.

113 RIGHT VENTRICULAR FREE WALL LONGITUDINAL STRAIN AS THE SOLE MARKER OF RIGHT VENTRICLE SYSTOLIC DYSFUNCION IN HYPERTROPHIC CARDIOMYOPATHY: A CLINICAL CASE

Abstract Background The introduction of Cardiac-MRI (cMRI) in clinical practice has considerably improved risk stratification of patients with hypertrophic cardiomyopathy (HCM). However, the prediction of adverse outcome based on imaging markers remains suboptimal. Right ventricular (RV) involvement is an emerging finding in this disease of unknown clinical value. The identification of accurate and sensible imaging markers to detect morpho-functional alterations of the RV is therefore essential to establish, in the future, any prognostic impact of RV involvement in HCM in order to improve risk stratification. RV free wall longitudinal strain (RV-FWLS) is a promising marker to unveil subclinical RV dysfunction despite normal conventional indices of RV systolic function; however, RV-FWLS has been scarcely explored in HCM patients. Case Summary A 29-year-old man with sarcomeric HCM due to MYBPC3 mutation was referred to our Institution. Trans-Thoracic Echocardiography (TTE) showed left ventricular (LV) apical hypertrophy (27 mm) with an ace of spades morphology and mid-ventricular obstruction (peak gradient 38 mmHg). LV-EF was normal (62%) while LV global longitudinal strain was significantly impaired (-9.3% with a reverse apical sparing pattern). 2nd-degree diastolic dysfunction and left atrial enlargement (maximum volume: 42 ml/m2) were observed. No LV apical aneurysm nor paradoxical diastolic flow at the apex were noted. RV hypertrophy was present (maximum thickness 8 mm) with normal conventional indices of RV systolic function: TAPSE 26 mm, S’ TDI 12 cm/s, FAC 50%. In contrast, RV-FWLS was significantly reduced (–16%). cMRI confirmed normal bi-ventricular function in presence of left and right hypertrophy (maximum wall thickness 28 and 12 mm, respectively) and LV apical thinning. At tissue characterization, elevated native T1 and T2 values were evident in the apex (1071 +/- 45 ms and 54 +/- 6 ms, respectively) and a significant amount of patchy LGE was present in the mid-apical segments of the LV (28% of LV mass) and of the RV. After consideration of clinical and imaging data, an s-ICD for primary prevention was implanted. Discussion The present case highlights known issues and poses new challenges in managing HCM patients. First, it confirms the central role of cMRI, demonstrating its unique capability to spot myocardial fibrosis, guiding our decision to implant an s-ICD in our patient. Second, it draws attention to RV involvement in HCM, an emerging finding in this condition. MYBPC3 mutation has been associated with RV hypertrophy. Both of these conditions, together with patchy RV-LGE, were found in our patient. Notably, RV-FWLS was the only RV systolic index to be impaired and might represent an early and more accurate marker of RV systolic dysfunction compared to other conventional indices, including RV-EF by cMRI. Future studies assessing the prognostic value of RV involvement, including RV-LGE and RV-FWLS, are needed in HCM patients to potentially refine risk stratification in this challenging population.

1051. Cardiac Assessment in Children with MIS-C: Late Magnetic Resonance Imaging Features

Abstract Background Multisystem Inflammatory Syndrome (MIS-C), a new entity in children which developed 2-4 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a severe condition. It can affect the multisystem, while the most severe manifestation is cardiac involvement. Left ventricular dysfunction, cardiogenic shock, coronary artery dilatation/aneurysm, valvulitis, pericardial effusion, arrhythmia, and conduction abnormalities were reported in approximately 80% of children with cardiovascular system involvement. It is still unclear the duration of the cardiac symptoms, and even they are permanent or persistent. Few studies evaluated persistent cardiac abnormalities by cardiac magnetic resonance imaging (MRI). Therefore, we aimed to assess persisting cardiac abnormalities with MIS-C by cardiac MRI and compare them with echocardiograms. Methods A retrospective study was conducted at a tertiary-level University Hospital between June 2020-July 2021. Thirty-four children diagnosed with MIS-C according to the criteria defined by the Centers for Disease Control and Prevention were retrospectively evaluated. Results The study included 17 males and 17 females with a mean age of 9.31±4.72 years. Initial echocardiographic evaluation showed cardiac abnormality in 18 (52.9%) patients; 4 (11.8%) pericardial effusion, 4 (11.8%) left ventricular ejection fraction (LVEF) &amp;lt; 55%, 5 (14.7%) LV fractional shortening &amp;lt; 30%, 5 (14.7%) coronary artery dilatation. Echocardiography showed normal LV systolic function in all patients at follow-up; coronary dilatation persisted in 2 of 5 (40 %) patients at the 6th-month visit. Cardiac MRI was performed in 31 (91.2%) patients. We didn’t detect abnormal T1 levels, whereas 9 (29%) had isolated elevated T2 values. 19 (61.3%) of 31 patients had at least one of the following findings: pericardial effusion, right ventricular dysfunction, LVEF abnormality. Conclusion Cardiac involvement persisted at a higher rate which was shown by cardiac MRI in the late period, particularly pericardial effusion. Cardiac MRI may be suggested for all MIS-C patients at a later phase. Prospective studies with larger sample sizes are needed to determine long-term cardiac effects. Disclosures All Authors: No reported disclosures.

Longitudinal hippocampal diffusion-weighted imaging and T2 relaxometry demonstrate regional abnormalities which are stable and predict subfield pathology intemporallobeepilepsy.

High-resolution (1 mm isotropic) diffusion tensor imaging (DTI) of the hippocampus in temporal lobe epilepsy (TLE) patients has shown patterns of hippocampal subfield diffusion abnormalities, which were consistent with hippocampal sclerosis (HS) subtype on surgical histology. The objectives of this longitudinal imaging study were to determine the stability of focal hippocampus diffusion changes over time in TLE patients, compare diffusion and quantitative T2 abnormalities of the sclerotic hippocampus, and correlate presurgical mean diffusivity (MD) and T2 maps with postsurgical histology. Nineteen TLE patients and 19 controls underwent two high-resolution (1 mm isotropic) DTI and 1.1 × 1.1 × 1 mm3 T2 relaxometry scans (in a subset of 16 TLE patients and 9 controls) of the hippocampus at 3T, with a 2.6 ± 0.8 year inter-scan interval. Within-participant hippocampal volume, MD and T2 were compared between the scans. Contralateral hippocampal changes 2.3 ± 1.0 years after surgery and ipsilateral preoperative MD maps versus postoperative subfield histopathology were evaluated in eight patients who underwent surgical resection of the hippocampus. Reduced volume and elevated MD and T2 of sclerotic hippocampi remained unchanged between longitudinal scans. Focal regions of elevated MD and T2 in bilateral hippocampi of HS TLE were detected consistently at both scans. Regions of high MD and T2 correlated and remained consistent over time. Volume, MD, and T2 remained unchanged in postoperative contralateral hippocampus. Regional elevations of MD identified subfield neuron loss on postsurgical histology with 88% sensitivity and 88% specificity. Focal T2 elevations identified subfield neuron loss with 75% sensitivity and 88% specificity. Diffusion and T2 abnormalities in ipsilateral and contralateral hippocampi remained unchanged between the scans suggesting permanent microstructural alterations. MD and T2 demonstrated good sensitivity and specificity to detect hippocampal subfield neuron loss on postsurgical histology, supporting the potential that high-resolution hippocampal DTI and T2 could be used to diagnose HS subtype before surgery.

T1 Mapping Values May Be Associated with Early Myocardial Involvement in Young Patients with Wilson Disease.

In young Asian patients with Wilson disease and no cardiac abnormalities or late gadolinium enhancement, cardiac MRI depicted elevated native T1, T2, and extracellular volume, suggesting early cardiac involvement.

Cardiac involvement in non-cirrhotic portal hypertension: MRI detects myocardial fibrosis and oedema similar to compensated cirrhosis.

The exact role of portal hypertension in cirrhotic cardiomyopathy remains unclear, and it is uncertain whether cardiac abnormalities also occur in non-cirrhotic portal hypertension (NCPH). This magnetic resonance imaging (MRI) study aimed to evaluate the presence of subclinical myocardial dysfunction, oedema, and fibrosis in NCPH. In this prospective study (2018-2022), participants underwent multiparametric abdominal and cardiac MRI including assessment of cardiac function, myocardial oedema, late gadolinium enhancement (LGE), and abdominal and cardiac mapping [T1 and T2 relaxation times, extracellular volume fraction (ECV)]. A total of 111 participants were included [44 participants with NCPH (48 ± 15 years; 23 women), 47 cirrhotic controls, and 20 healthy controls]. The cirrhotic group was dichotomized (Child A vs. Child B/C). NCPH participants demonstrated a more hyperdynamic circulation compared with healthy controls (cardiac index: 3.7 ± 0.6 vs. 3.2 ± 0.8 L/min/m², P = 0.004; global longitudinal strain: -27.3 ± 4.6 vs. -24.6 ± 3.5%, P = 0.022). The extent of abnormalities indicating myocardial fibrosis and oedema in NCPH was comparable with Child A cirrhosis (e.g. LGE presence: 32 vs. 33 vs. 69%, P = 0.004; combined T1 and T2 elevations: 46 vs. 27 vs. 69%, P = 0.017; NCPH vs. Child A vs. Child B/C). Correlations between splenic T1 and myocardial T1 values were found (r = 0.41; P = 0.007). Splenic T1 values were associated with the presence of LGE (odds ratio, 1.010; 95% CI: 1.002, 1.019; P = 0.013). MRI parameters of myocardial fibrosis and oedema were altered in participants with NCPH to a similar extent as in compensated cirrhosis and were associated with splenic markers of portal hypertension, indicating specific portal hypertensive cardiomyopathy.

Early myocardial oedema can predict subsequent cardiomyopathy in high-dose anthracycline therapy.

This study aims to assess subclinical changes in functional and morphologic myocardial MR parameters very early into a repetitive high-dose anthracycline treatment (planned cumulative dose >650mg/m2 ), which may predict subsequent development of anthracycline-induced cardiomyopathy (aCMP). Thirty sarcoma patients with previous exposition of 300-360mg/m2 doxorubicin-equivalent chemotherapy who were planned for a second treatment of anthracycline-based chemotherapy (360mg/m2 doxorubicin-equivalent) were recruited. Enrolled individuals received three CMR studies (before treatment, 48h after first anthracycline treatment and upon completion of treatment). Native T1 mapping (MOLLI 5s(3s)3s), T2 mapping, and extracellular volume (ECV) maps were acquired in addition to a conventional CMR with SSFP-cine imaging at 1.5T. Patients were given 0.2mmol/kg gadoteridol for ECV quantification and LGE imaging. Blood samples for cardiac biomarkers were obtained before each scan. Development of relevant aCMP was defined as drop of left ventricular ejection fraction (LVEF) by >10% compared with baseline. Twenty-three complete datasets were available for analysis. Median treatment time was 20.7±3.0weeks. Eight patients developed aCMP with LVEF reduction >10% until end of chemotherapy. Baseline LVEF was not different between patients with and without subsequent aCMP. Patients with aCMP had decreased LV mass upon completion of therapy (99.4±26.5g vs. 90.3±24.8g; P=0.02), whereas patients without aCMP did not show a change in LV mass (91.5±20.0g vs. 89.0±23.6g; P>0.05). On strain analysis, GLS (-15.3±1.3 vs. -13.4±1.6; P=0.02) and GCS (-16.7±2.1 vs. -14.9±2.6; P=0.04) were decreased in aCMP patients upon completion of therapy, whereas non-aCMP individuals showed no change in GLS (-15.4±3.3 vs. -15.4±3.4; P=0.97). When assessed 48h after first dose of anthracyclines, patients with subsequent aCMP had significantly elevated myocardial T2 times compared with before therapy (53.0±2.8ms vs. 49.3±5.2ms, P=0.02) than patients who did not develop aCMP (50.7±5.1ms vs. 51.1±3.9ms, P>0.05). Native T1 times decreased at 48h after first dose irrespective of development of subsequent aCMP (1020.2±28.4ms vs. 973.5±40.3ms). Upon completion of therapy, patients with aCMP had increased native T1 compared with baseline (1050.8±17.9ms vs. 1022.4±22.0ms; P=0.01), whereas non-aCMP patients did not (1034.5±46.6ms vs. 1018.4±29.7ms; P=0.15). No patient developed new myocardial scars or compact myocardial fibrosis under chemotherapy. Cardiac biomarkers were elevated independent of development of aCMP. With high cumulative anthracycline doses, early increase of T2 times 48h after first treatment with anthracyclines can predict the development of subsequent aCMP after completion of chemotherapy. Early drop of native T1 times occurs irrespective of development of aCMP in high-dose anthracycline therapy.

Native T1 Mapping for the Diagnosis of Myocardial Fibrosis in Patients With Chronic Myocardial Infarction

BackgroundMyocardial fibrosis is a fundamental process in cardiac injury. Cardiac magnetic resonance native T1 mapping has been proposed for diagnosing myocardial fibrosis without the need for gadolinium contrast. However, recent studies suggest that T1 measurements can be erroneous in the presence of intramyocardial fat. ObjectivesThe purpose of this study was to investigate whether the presence of fatty metaplasia affects the accuracy of native T1 maps for the diagnosis of myocardial replacement fibrosis in patients with chronic myocardial infarction (MI). MethodsConsecutive patients (n = 312) with documented chronic MI (>6 months old) and controls without MI (n = 50) were prospectively enrolled. Presence and size of regions with elevated native T1 and infarction were quantitatively determined (mean + 5SD) on modified look-locker inversion-recovery and delayed-enhancement images, respectively, at 3.0-T. The presence of fatty metaplasia was determined using an out-of-phase steady-state free-precession cine technique and further verified with standard fat-water Dixon methods. ResultsNative T1 mapping detected chronic MI with markedly higher sensitivity in patients with fatty metaplasia than those without fatty metaplasia (85.6% vs 13.3%) with similar specificity (100% vs 98.9%). In patients with fatty metaplasia, the size of regions with elevated T1 significantly underestimated infarct size and there was a better correlation with fatty metaplasia size than infarct size (r = 0.76 vs r = 0.49). In patients without fatty metaplasia, most of the modest elevation in T1 appeared to be secondary to subchronic infarcts that were 6 to 12 months old; the T1 of infarcts >12 months old was not different from noninfarcted myocardium. ConclusionsNative T1 mapping is poor at detecting replacement fibrosis but may indirectly detect chronic MI if there is associated fatty metaplasia. Native T1 mapping for the diagnosis and characterization of myocardial fibrosis is unreliable.

Abstract 10211: Cardiac MR Overlay Guides Endomyocardial Biopsy in Pediatric Transplant Patients Towards Regions of Interest

Introduction: Endomyocardial biopsy (EMB) drives rejection diagnosis in pediatric heart transplant patients but is subject to false negatives. Cardiac magnetic resonance imaging (CMR) can detect and quantify fibrosis and edema with T1 and T2 mapping. Overlaying CMR data onto X-ray images may be used for EMB procedural guidance. Hypothesis: Overlaying segmented T1 and T2 map images onto X-ray for EMB guidance may improve diagnosis of rejection in pediatric transplant patients. Methods: 30 pediatric heart transplant patients referred for clinically indicated EMB underwent noncontrast CMR with T1 and T2 mapping prior to EMB. If present, regions of T1 and T2 elevation were segmented and exported as an overlay image. Biopsies were obtained without ( unguided ) and then with ( guided ) CMR overlay with T1 and T2 “hotspots”. Each biopsy specimen received a rejection grade, blinded to guided vs. unguided. As a surrogate for clinical rejection, treatment decisions were made without knowledge of CMR results, and logged as no change, oral therapy augmentation, or IV therapy initiation. Treatment category and pathologic grade were compared among biopsies with Fisher’s exact test and logistic regression. Results: 30 patients (median age 13 years (interquartile range (IQR) 8.8, 16.2), BSA 1.36 m2 (IQR 1.09, 1.86), 50% male) underwent 64 encounters for a total of 199 biopsied specimens (58 guided, 141 unguided). Hotspots were identified in 75% (48/64) of encounters, with 69% (33/48) in biopsied regions of the right ventricle allowing for guidance (25 T1 and 8 T2). Patients with T1 or T2 hotspots providing guided EMB were twice as likely to require any augmentation of therapy compared to those with unguided EMB (38% guided vs 17% unguided, p=0.001). Incidence of pathologic biopsy results (grade &gt; 0) was not significantly different between guided and unguided biopsies from the same patients (41% vs 40%, p =0.99). Conclusions: Patients with T1/T2 hotspots on CMR and guided EMB require rejection treatment more frequently than patients with only unguided biopsies, although biopsy grade did not significantly differ within the same patient. Future work will evaluate relationship of CMR T1 and T2 hotspots to treatment, which may establish CMR as a superior screening tool for rejection.

Abstract 14366: Young, Healthy Female With Myocarditis and Cardiogenic Shock After Mild COVID-19 Infection

Background: We present a case of a young female with no pre-existent conditions, who presented to the hospital one month after a mild COVID-19 infection with severe myocarditis complicated by cardiogenic shock. Case: A 40-year-old female with no prior medical history and a regular, vigorous exercise program developed a mild COVID-19 infection with symptoms of mild fatigue, myalgias, chills, fever, and loss of taste, which resolved within a week. A month later, she presented to the hospital with exertional dyspnea, weakness, chest pressure, abdominal pain, and fatigue. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 15% with a severely dilated left ventricle, global hypokinesis and severe mitral regurgitation. Right heart catheterization demonstrated cardiogenic shock with a cardiac index of 1.4 liters per minute by Fick equation, and she was admitted to the cardiac intensive care unit. Cardiac magnetic resonance revealed subepicardial delayed enhancement along the lateral and inferolateral walls and elevated T1 mapping consistent with myocarditis. A right ventricle biopsy revealed myocyte hypertrophy and patchy interstitial fibrosis without evidence of inflammatory tissue. She was diuresed, supported with inotropic therapy, and empirically treated with high doses of glucocorticoids. She clinically improved with weaning of inotropes and was discharged in stable condition on goal-directed medical therapy after 2.5 weeks. Conclusion: This patient represents a case of severe cardiogenic shock, after initial infection and in the absence of previously identified risk factors for development of COVID myocarditis. The absence of inflammatory tissue on pathology raises questions regarding the centrality of inflammatory processes in COVID-19-related myocardial injury leading to “long COVID” syndrome. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.

Baseline cartilage T1ρ and T2 predicted patellofemoral joint cartilage lesion progression and patient-reported outcomes after ACL reconstruction.

This study aims to determine if baseline T1ρ and T2 will predict cartilage morphological lesion progression in the patellofemoral joint (PFJ) and patient-reported outcomes at 2-year after anterior cruciate ligament (ACL) reconstruction (ACLR). Thirty-nine ACL-injured patients were studied at baseline and two-year after ACLR. 3 T MR T1ρ and T2 images and Knee Injury and Osteoarthritis Outcome Score (KOOS) were acquired at both time points. Voxel-based relaxometry (VBR) technique was used to detect local cartilage abnormalities. Patients were divided into progression and non-progression groups based on changes of the whole-organ magnetic resonance imaging scoring (WORMS) grading of cartilage in PFJ from baseline to 2-year, and into lower (more pain) and higher (less pain) KOOS pain groups based on 2-year KOOS pain scores, separately. Voxel-based analyses of covariance were used to compare T1ρ and T2 values at baseline between the defined groups. Using VBR analysis, the progression group at 2-year showed higher T1ρ and T2 compared with the non-progression group at baseline, with the medial femoral condyle showing the largest areas with significant differences. At two-year, 56% of patients were able to recover with respect to KOOS pain. The lower KOOS pain group at 2-year showed significantly elevated T1ρ and T2 in the patella at baseline compared with the higher KOOS pain group. In conclusion, baseline T1ρ and T2 mapping, combined with VBR analysis, may help identify ACLR patients at high risk of developing progressive PFJ cartilage lesions and worse clinical symptoms 2-year after surgery.

Manganese-Enhanced Magnetic Resonance Imaging in Takotsubo Syndrome.

Takotsubo syndrome is an acute cardiac emergency characterized by transient left ventricular systolic dysfunction typically following a stressful event. Despite its rapidly rising incidence, its pathophysiology remains poorly understood. Takotsubo syndrome may pass unrecognized, especially if timely diagnostic imaging is not performed. Defective myocardial calcium homeostasis is a central cause of contractile dysfunction and has not been explored in takotsubo syndrome. We aimed to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phases of takotsubo syndrome. Twenty patients with takotsubo syndrome (63±12 years of age; 90% female) and 20 volunteers matched on age, sex, and cardiovascular risk factors (59±11 years of age; 70% female) were recruited from the Edinburgh Heart Centre between March 2020 and October 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during index hospitalization with repeat manganese-enhanced magnetic resonance imaging performed after at least 3 months. Compared with matched control volunteers, patients had a reduced left ventricular ejection fraction (51±11 versus 67±8%; P<0.001), increased left ventricular mass (86±11 versus 57±14 g/m2; P<0.001), and, in affected myocardial segments, elevated native T1 (1358±49 versus 1211±28 ms; P<0.001) and T2 (60±7 versus 38±3 ms; P<0.0001) values at their index presentation. During manganese-enhanced imaging, kinetic modeling demonstrated a substantial reduction in myocardial manganese uptake (5.1±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min], respectively; P<0.0001), consistent with markedly abnormal myocardial calcium handling. After recovery, left ejection fraction, left ventricular mass, and T2 values were comparable with those of matched control volunteers. Despite this, native and postmanganese T1 and myocardial manganese uptake remained abnormal compared with matched control volunteers (6.6±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min]; P<0.0001). In patients with takotsubo syndrome, there is a profound perturbation of myocardial manganese uptake, which is most marked in the acute phase but persists for at least 3 months despite apparent restoration of normal left ventricular ejection fraction and resolution of myocardial edema, suggesting abnormal myocardial calcium handling may be implicated in the pathophysiology of takotsubo syndrome. Manganese-enhanced magnetic resonance imaging has major potential to assist in the diagnosis, characterization, and risk stratification of patients with takotsubo syndrome. URL: https://www. gov; Unique identifier: NCT04623788.

Applying quantitative CMR parameters for detecting myocardial lesion in immune checkpoint inhibitors-associated myocarditis

PurposeSparse researches evaluated the quantitative cardiovascular magnetic resonance (CMR) parameters for immune checkpoint inhibitors (ICI)-associated myocarditis. We aimed to apply quantitative CMR mappings and late gadolinium enhancement (LGE) extent for detecting ICI-associated myocarditis. MethodThe retrospective study included patients with ICI-associated myocarditis and CMR examination from August 2018 to August 2021 in our hospital. ICI-associated myocarditis was clinically diagnosed based on the clinical criteria by European Society of Cardiology guidelines. The multiparametric CMR images including T2 mapping and black blood T2-weighted images were used to evaluate myocardial edema. The myocardial edema ratio (ER) ≥ 2.0 was applied for determining myocardial edema on T2-weighted images. Results56 patients with ICI-associated myocarditis were included. The global T2 value and native T1 value of patients with ICI-associated myocarditis were significantly higher than the reference ranges in our hospital (p < 0.05). The rate of elevated global T2 value (92%) was significantly higher than those of abnormal native T1 value (73%), ER (52%) and LGE presence (68%) in patients with ICI-associated myocarditis (p < 0.05). The LGE extent and left ventricular ejection fraction of patients with ICI-associated myocarditis were 10.38 ± 9.64% and 56.42 ± 8.54%, respectively. LGE extent inversely correlated with left ventricular ejection fraction (r = -0.38, p = 0.004) but positively correlated with native T1 value (r = 0.28, p < 0.04) and extracellular volume (r = 0.50, p = 0.001). ConclusionsT2 mapping could detect higher rate of patients with ICI-associated myocarditis than native T1 mapping, ER and LGE presence. LGE extent inversely correlated with left ventricular ejection fraction but positively correlated with native T1 value and extracellular volume in patients with ICI-associated myocarditis.