Cardiac Magnetic Resonance Evaluation Research Articles

Cardiac Magnetic Resonance Evaluation of Athletic Males With Reduced Anerobic Exercise Capacity and Anabolic Steroid Use

Cardiac Magnetic Resonance Evaluation of Athletic Males With Reduced Anerobic Exercise Capacity and Anabolic Steroid Use

Cardiac magnetic resonance reveals concealed structural heart disease in patients with frequent premature ventricular contractions and normal echocardiography: A systematic review

Premature ventricular contractions (PVCs) are a common form of arrhythmic events, often representing an idiopathic and benign condition without further therapeutic interventions. However, in certain circumstances PVCs may represent the epiphenomenon of a concealed structural heart disease (SHD). Surface 12‑leads EKG and 24-h dynamic EKG are necessary to assess their main characteristics such as site of origin, frequency and complexity. Echocardiography represents the first-line imaging tool recommended to evaluate cardiac structures and function. Cardiac Magnetic Resonance (CMR) is recognized as a superior modality for detecting structural cardiac alterations, that might evade detection by conventional echocardiography. Moreover, in specific populations such as athletes, CMR may have a crucial role to exclude a concealed SHD and the risk of serious arrhythmic events during sport activity. Some clinical characteristics such as male sex, older age or family history of sudden cardiac death (SCD) or cardiomyopathy, and some electrocardiographic features of PVCs, in particular a right branch bundle block (RBBB) with superior/intermediate axis morphology, the reproducibility of VAs during exercise test (ET) or the evidence of complex ventricular arrhythmias, may warrant a CMR evaluation, due to the high probability of SHD. In this systematic review our objective was to provide an exhaustive overview on the role of CMR in detecting a concealed SHD in patients with high daily burden of PVCs and a normal echocardiographic evaluation, paving the way for a more extensive utilization of CMR in presence of certain high-risk clinical and/or EKG features identified during the diagnostic workup.

The Role of T2 Mapping in Cardiac Amyloidosis.

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy divided into two types: light-chain (LA) and transthyretin (ATTR) CA. Cardiac magnetic resonance (CMR) has emerged as an important diagnostic tool in CA. While late gadolinium enhancement (LGE), T1 mapping and extracellular volume (ECV) have a consolidate role in the assessment of CA, T2 mapping has been less often evaluated. We aimed to test the value of T2 mapping in the evaluation of CA. This study recruited 70 patients with CA (51 ATTR, 19 AL). All the subjects underwent 1.5 T CMR with T1 and T2 mapping and cine and LGE imaging. Their QALE scores were evaluated. The myocardial T2 values were significantly (p < 0.001) increased in both types of CA compared to the controls. In the AL-CA group, increased T2 values were associated with a higher QALE score. The myocardial native T1 values and ECV were significantly (p < 0.001) higher in the CA patients than in the healthy subjects. Left ventricular (LV) mass, QALE score and ECV were higher in ATTR amyloidosis compared with AL amyloidosis, while the LV ejection fraction was lower (p < 0.001). These results support the concept of the presence of myocardial edema in CA. Therefore, a CMR evaluation including not only myocardial T1 imaging but also myocardial T2 imaging allows for more comprehensive tissue characterization in CA.

Right ventricular scalloping index as cardiac magnetic resonance-derived marker for diagnosis of arrhythmogenic right ventricular cardiomyopathy.

The cardiac magnetic resonance (CMR) evaluation of right ventricular (RV) morphologic abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is subjective. Here, we aimed to use a quantitative index, the right ventricular scalloping index (RVSI), to standardize the measurement of RV free wall scalloping and aid in the imaging diagnosis. We retrospectively included 15 patients with definite ARVC and 45 age- and sex-matched patients with idiopathic right ventricular outflow tract ventricular arrhythmia (RVOT-VA) as controls. The RVSI was measured from cine images on four-chamber view to evaluate its ability to distinguish between ARVC and RVOT-VA patients. Other cardiac functional parameters including strain analysis were also performed. The RVSI was significantly higher in the ARVC than RVOT-VA group (1.56 ± 0.23 vs 1.30 ± 0.08, p < 0.001). The diagnostic performance of the RVSI was superior to the RV global longitudinal, circumferential, and radial strains, RV ejection fraction, and RV end-diastolic volume index. The RVSI demonstrated high intraobserver and interobserver reliability (intraclass correlation coefficient, 0.94 and 0.96, respectively). RVSI was a strong discriminator between ARVC and RVOT-VA patients (area under curve [AUC], 0.91; 95% CI, 0.82-0.99). A cutoff value of RVSI ≥1.49 provided an accuracy of 90.0%, specificity of 97.8%, sensitivity of 66.7%, positive predictive value (PPV) of 90.9%, and a negative predictive value (NPV) of 89.8%. In a multivariable analysis, a family history of ARVC or sudden cardiac death (odds ratio, 38.71; 95% CI, 1.48-1011.05; p = 0.028) and an RVSI ≥1.49 (odds ratio, 64.72; 95% CI, 4.58-914.63; p = 0.002) remained predictive of definite ARVC. RVSI is a quantitative method with good performance for the diagnosis of definite ARVC.

Comparing Strain Assessment in Compressed Sensing and Conventional Cine MRI.

The aim of this study is to assess the feasibility of compressed sensing (CS) acceleration methods compared to conventional segmented cine (Seg) cardiac magnetic resonance (CMR) for evaluating left ventricular (LV) function and strain by feature tracking (FT). In this prospective study, 45 healthy volunteers underwent CMR imaging used Seg, threefold (CS3), fourfold (CS4), and eightfold (CS8) CS acceleration. Cine images were scored for quality (1-5 scale). LV volumetric and functional parameters and global longitudinal (GLS), circumferential (GCS), and radial strains (GRS) were quantified. LV volumetric and functional parameters exhibited no differences between Seg and all CS cines (all P > 0.05). The strains were similar for Seg, CS3, and CS4 (all P > 0.05). Similarly, no significant differences were observed in GRS and GCS between Seg and CS8 (all P > 0.05), but the global longitudinal strain was significantly lower for CS8 versus Seg (P < 0.001). Image quality declined with CS acceleration, especially in long-axis views with CS8. CS cine MRI at acceleration factor 4 maintained good image quality and accurate measurements of LV function and strain, although there was a slight reduction in the quality of long-axis images and GLS with CS8. CS acceleration up to a factor of 4 enabled fast CMR evaluations, making it suitable for clinical use.

Kiosk 6R-FB-07 - Evaluation of Cardiac Magnetic Resonance Based Tissue Characterization in Individuals with Positron Emission Tomography-confirmed Coronary Microvascular Disease

Kiosk 6R-FB-07 - Evaluation of Cardiac Magnetic Resonance Based Tissue Characterization in Individuals with Positron Emission Tomography-confirmed Coronary Microvascular Disease

Cardiac magnetic resonance evaluation in recipients of hepatitis c virus-infected donor hearts

Hepatitis C Virus positive (HCV+) organ donors offer a viable strategy for expansion of the heart donor pool without an increased risk of recipient mortality. Cardiac magnetic resonance imaging (CMR) is an effective tool for graft surveillance in heart transplant (HT) recipients. However, there are no data comparing CMR findings in HT recipients based on donor HCV status. The aim of this propensity score matched case-control study was to evaluate baseline CMR characteristics of HCV+ HT recipients and HCV- HT recipients, as well as compare cardiac allograft structure, function, performance, and tissue characterization between groups. CMR normative values did not differ between groups in matched analysis. There were no significant differences in CMR-derived biventricular function, strain, LGE, or myocardial tissue characteristics by parametric mapping. This study suggests CMR can be a valuable tool for surveillance in HCV+ HT patients, and abnormalities on imaging should not be attributed to HCV infection.

Predictive value of a comprehensive atrial assessment with cardiac magnetic resonance in non-ischemic cardiomyopathy: keep it simple.

Cardiac magnetic resonance (CMR) can provide a multi-parametric evaluation of left atrial (LA) size and function. A complete CMR-based LA assessment might improve the risk stratification of patients with non-ischemic dilated cardiomyopathy (DCM). We performed a comprehensive CMR-based evaluation of LA size and function, in order to assess the prognostic impact of specific LA parameters in DCM. Secondary analysis of a prospective registry (UHSM-CMR study, NCT02326324) including 648 consecutive patients with DCM and CMR evaluation of LA area and LA length. Of these, 456 had complete LA assessment covering reservoir, conduit and booster pump function and including LA reservoir strain evaluated with feature tracking. The heart failure (HF) endpoint included HF hospitalizations, HF death and heart transplant. The arrhythmic endpoint included ventricular arrhythmias (VA) (sustained or treated by implantable defibrillator) and sudden death (SD). At median follow-up of 23 months, 34 patients reached the HF endpoint; in a multivariable model including NYHA class and LVEF, LA length had incremental predictive value. LA length ≥ 69mm was the best cut-off to predict HF events (adjusted HR 2.3, p = 0.03). Among the 456 patients with comprehensive LA assessment, only LA length was independently associated with the HF endpoint after adjusting for LVEF and NYHA class. By contrast, no LA parameter independently predicted the arrhythmic risk. In DCM patients, LA length is an independent predictor of HF events, showing stronger association than other more complex parameters of LA function. No atrial parameter predicts the risk of VA and SD.

Basal septal T1 mapping and extracellular volume as discriminators in cardiac magnetic resonance evaluation of myocardial involvement in advanced Anderson-Fabry disease: a case description.

Basal septal T1 mapping and extracellular volume as discriminators in cardiac magnetic resonance evaluation of myocardial involvement in advanced Anderson-Fabry disease: a case description.

Long-term cardiotoxicity in germ cell cancer survivors after platinum-based chemotherapy: cardiac MR shows impaired systolic function and tissue alterations

ObjectivesLong-term toxicities of germ cell cancer (GCC) treatment are of particular importance in young men with a life expectancy of several decades after curative treatment. This study aimed to investigate the long-term effects of platinum-based chemotherapy on cardiac function and myocardial tissue in GCC survivors by cardiac magnetic resonance (CMR) imaging.MethodsAsymptomatic GCC survivors ≥ 3 years after platinum-based chemotherapy and age-matched healthy controls underwent CMR assessment, including left ventricular (LV) and right ventricular (RV) ejection fraction (EF), strain analysis, late gadolinium enhancement (LGE) imaging, and T1/T2 mapping.ResultsForty-four survivors (age 44 [interquartile range, IQR 37–52] years; follow-up time 10 [IQR 5–15] years after chemotherapy) and 21 controls were evaluated. LV- and RVEF were lower in GCC survivors compared to controls (LVEF 56 ± 5% vs. 59 ± 5%, p = 0.017; RVEF 50 ± 7% vs. 55 ± 7%, p = 0.008). Seven percent (3/44) of survivors showed reduced LVEF (< 50%), and 41% (18/44) showed borderline LVEF (50–54%). The strain analysis revealed significantly reduced deformation compared to controls (LV global longitudinal strain [GLS] -13 ± 2% vs. -15 ± 1%, p < 0.001; RV GLS -15 ± 4% vs. -19 ± 4%, p = 0.005). Tissue characterization revealed focal myocardial fibrosis in 9 survivors (20%) and lower myocardial native T1 times in survivors compared to controls (1202 ± 25 ms vs. 1226 ± 37 ms, p = 0.016). Attenuated LVEF was observed after two cycles of platinum-based chemotherapy (54 ± 5% vs. 62 ± 5%, p < 0.001).ConclusionBased on CMR evaluation, combination chemotherapy with cumulative cisplatin ≥ 200 mg/m2 is associated with attenuated biventricular systolic function and myocardial tissue alterations in asymptomatic long-term GCC survivors.Clinical relevance statementPlatinum-based chemotherapy is associated with decreased systolic function, non-ischemic focal myocardial scar, and decreased T1 times in asymptomatic long-term germ cell cancer survivors. Clinicians should be particularly aware of the risk of cardiac toxicity after platinum-based chemotherapy.Key Points• Platinum-based chemotherapy is associated with attenuation of biventricular systolic function, lower myocardial T1 relaxation times, and non-ischemic late gadolinium enhancement.• Decreased systolic function and non-ischemic late gadolinium enhancement are associated with a cumulative cisplatin dose of ≥ 200 mg/m2.• Cardiac MRI can help to identify chemotherapy-associated changes in cardiac function and tissue in asymptomatic long-term germ cell cancer survivors.Graphical

Assessment of left ventricular myocardial fibrosis in adult patients with Ebstein's anomaly: a retrospective cohort study based on cardiac magnetic resonance and histopathological samples

Abstract Background The relationship between Ebstein's Anomaly (EA) and myocardial fibrosis in the left ventricle (LV) has been debated. This study aimed to determine the prevalence of replacement fibrosis in the LV using cardiac magnetic resonance (CMR) imaging and correlate it with histopathological findings. The study also investigated whether LV fibrosis is an independent risk factor for cardiovascular disease (CVD) mortality and developed a risk score for this purpose. Methods We performed a twelve-years (2009-2021) retrospective cohort study of adult patients with EA who underwent CMR. The CMR evaluation included a comprehensive assessment of myocardial fibrosis by late gadolinium enhancement (LGE). Four post-mortem samples were obtained from our cohort and stained using Masson trichrome to characterize LV-fibrosis. We used Cox-Regression analysis to identify and derive a prediction score that associates LV-fibrosis with CVD-mortality. Results We included 57 adults with EA (52% male, median age 29.52, IQR: 21.24-39.17 years). LGE prevalence by CMR was observed in 52.6% (95% CI: 39.9%-66.0%) in any chamber; LGE-LV in 29.8% (95% CI: 19.5%-42.7%). Histopathological findings revealed a mid-wall pattern with predominantly interstitial fibrosis and minimal replacement fibrosis. LV-fibrosis was associated with increased risk for CVD mortality (HR: 6.02, 95% CI: 1.22-19.91) attributable to lateral and mid-wall LV segment involvement. Our mortality score achieved an overall good prediction capacity (C-statistic: 0.93, Dxy= 0.86). Conclusions There is a high prevalence of replacement LV fibrosis in adults with EA, characterized by specific CMR and histological patterns. Furthermore, LV fibrosis is an independent predictor of CVD mortality, which could be integrated into a risk assessment in clinical management.Figure 1.CMR and pathological imagesFigure 1.Kaplan-Meier analysis

Tissue characterization of benign cardiac tumors by cardiac magnetic resonance imaging, a review of core imaging protocol and benign cardiac tumors.

Generally, cardiac masses are initially suspected on routine echocardiography. Cardiac magnetic resonance (CMR) imaging is further performed to differentiate tumors from pseudo-tumors and to characterize the cardiac masses based on their appearance on T1/T2-weighted images, detection of perfusion and demonstration of gadolinium-based contrast agent uptake on early and late gadolinium enhancement images. Further evaluation of cardiac masses by CMR is critical because unnecessary surgery can be avoided by better tissue characterization. Different cardiac tissues have different T1 and T2 relaxation times, principally owing to different internal biochemical environments surrounding the protons. In CMR, the signal intensity from a particular tissue depends on its T1 and T2 relaxation times and its proton density. CMR uses this principle to differentiate between various tissue types by weighting images based on their T1 or T2 relaxation times. Generally, tumor cells are larger, edematous, and have associated inflammatory reactions. Higher free water content of the neoplastic cells and other changes in tissue composition lead to prolonged T1/T2 relaxation times and thus an inherent contrast between tumors and normal tissue exists. Overall, these biochemical changes create an environment where different cardiac masses produce different signal intensity on their T1- weighted and T2- weighted images that help to discriminate between them. In this review article, we have provided a detailed description of the core CMR imaging protocol for evaluation of cardiac masses. We have also discussed the basic features of benign cardiac tumors as well as the role of CMR in evaluation and further tissue characterization of these tumors.

Late gadolinium enhancement persistence in early cardiac magnetic resonance follow-up after acute myocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Multiparametric cardiac magnetic resonance (CMR) evaluation with modified Lake Louise criteria (mLLC) is the gold standard non-invasive test for the diagnosis of acute myocarditis. Although CMR in the follow-up may inform of edema resolution and myocardial fibrosis there is a lack of consensus on the optimal time interval to perform it and the clinical and prognostic differences between patients with complete resolution and those who present late gadolinium enhancement (LGE) persistence. Purpose To describe the clinical profile, CMR findings, early CMR follow-up and clinical events in patients with acute myocarditis focusing on the differences between patients who present complete LGE resolution versus patients with LGE persistence. Methods All patients who underwent a CMR for a suspected myocarditis during a period of 1 year from June 2021 to June 2022 were retrospectively evaluated. Those with a confirmed myocarditis by mLLC and a follow-up CMR were included. Electronic medical records were analyzed to collect data on baseline clinical variables, CMR features and follow-up events. Follow-up CMR was performed on follow-up based on clinician’s criteria. Results A total of 27 patients fulfilled mLLC for myocarditis during the period of study and had a follow-up CMR. The mean time to first CMR control was 186 +/- 95 days (6,2 months). Of those 23 (85.2%) presented persistent LGE enhancement and 4 of them presented a complete resolution of LGE. There were no statistically significant differences between groups although patients with complete LGE resolution tend to be younger. There were no differences between groups in terms of LVEF and RVEF. Patients with persistent LGE in the follow-up tend to have higher edema and LGE extension during the acute myocarditis episode, being the LGE difference statistically significant. In the follow up CMR almost all patients presented edema resolution and although the majority of patients (85.2%) presented LGE persistence they presented a trend to a decrease of affected segments (4.4 to 3.1 after mean time of 6 months). There were no differences in clinical events between groups in terms of death, admissions, ventricular arrhythmias and new episodes of myocarditis, patients with persistent LGE tend to have more visits for unresolved chest pain. Conclusions The majority of patients with a confirmed acute myocarditis had edema resolution and LGE persistence after 6 months. There were no differences in clinical events during follow-up. Follow up CMR before 6 months can prove resolving edema but LGE persistance is common. Further studies are needed to define the optimal interval to perform CMR after the index event.

Acute effects of interruption of cardiac resynchronization therapy on left ventricular morpho-functional parameters as assessed by cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac resynchronization therapy (CRT) has become a standard treatment for patients with heart failure with reduced ejection fraction (HFrEF) and left ventricular (LV) dyssynchrony. Both immediate and long-term clinical and functional improvement have been reported after CRT implementation, as well as a decrease in the mortality and hospitalization rates. Recently, it has been questioned whether, once LV function has improved and reverse LV remodeling has occurred, ongoing biventricular pacing is still necessary. Purpose To assess by cardiac magnetic resonance (CMR) the acute effect on LV systolic function and dimensions of discontinuing CRT in patients with HFrEF. Methods The study prospectively included a small cohort of patients with HFrEF (7 males and 1 female; mean age 63.7 ± 2.5 years; ischemic etiology in 50%) receiving an MR-conditional CRT device in accordance with the existing guidelines. CMR examinations have been performed before (pre-CRT) and after 6 months after CRT implantation (post-CRT). Each follow-up CMR study included two full sets of cine images for the evaluation of LV systolic function and volumes obtained, respectively, before (post-CRTON) and after (post-CRTOFF) disabling the CRT function on the device. To warrant patient safety, each post-CRT CMR study was performed following institutional protocols based on specific guidelines for patients with MR-conditional cardiac implantable electronic devices (CIEDs). Results No adverse events or significant changes in the CIEDs parameters (including pacing and sensing thresholds and battery level) were recorded during the follow-up CMR studies. At post-CRT evaluation, CMR image quality was judged to be at least sufficient for analysis in all patients. As compared with the basal pre-CRT study, a significant increase in LVEF was detected at the post-CRTON CMR evaluation (28,1 vs 35,0%; p &amp;lt;0,05) (Figure 1), together with a clear trend towards a decrease in LV end-diastolic volume [LVEDV] (118.72 ± 11.00 mL vs. 107.5 ± 13.86 mL; p = n.s) and LV end-systolic volume [LVESV] (87.12 ± 9.40 mL vs. 71.125 ± 11.26 mL; p = n.s.) (Figure 2). No relevant changes were detected when re-assessing the same LV parameters by CMR immediately after switching off the CRT function (post-CRTOFF study), with persisting increase in LVEF (37.9 ± 4.5%; p &amp;lt;0,05 vs. pre-CRT) and tendency towards decreased LVEDV (97.3 ± 12.3 mL; p = n.s. vs. pre-CRT) and LVESV (63.0 ± 11.4 mL; p = n.s. vs. pre-CRT). Conclusion These preliminary findings show that favorable changes induced on LV function and remodeling by prolonged CRT in HFrEF patients are not promptly lost after the interruption of the electrical therapy. Whether a longer CRT interruption would determine more pronounced variations in the LV parameters or if the effects of CTR discontinuation may be related to the effective length of the period of time between implantation and cessation of the therapy deserve further investigation.

Myocardial edema at CMR imaging end evolution of ventricular function following COVID-19 myocarditis - insights from the CARDIOCOV study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): The CARDIOCOV project - Prototype for personalized assessment of cardiovascular risk and post-Covid myocarditis based on artificial intelligence, advanced medical imaging and cloud computing - financed by UEFISCDI PN-III-P2-2.1-PTE-2021-0450 (Contract Number 108PTE/2022). Background Myocarditis following SARS-COV-2 infection has recently become a subject of concern, being detected in a significant number of post-COVID-19 patients who undergo cardiac magnetic resonance(CMR) examination. While the role of CMR in detecting presence of viral myocarditis has been well established, the CMR features associated with significant alteration of ventricular function in post-COVID patients are not clearly identified yet. Purpose The aim of the study was to investigate the role of myocardial edema (ME) at CMR for predicting the evolution of ventricular function in patients with COVID myocarditis. Methods In total, 55 patients with CMR signs of viral myocarditis following COVID-19 infection (52.72% males, mean age 36.85+/-16.29) were enrolled in the study. The delayed gadolinium enhancement phase-sensitive inversion recovery sequences were used for characterization of the myocardial tissue, and inversion recovery images showing high signal intensity were considered suggestive of edematous changes. Patients were divided into 2 study groups, according to the presence of myocardial edema at the moment of CMR evaluation: group 1 (n=18, 32.72%) - patients without ME, and group 2 (n=37, 67.27%)-patients with ME identified by CMR. In all patients, end-distolic and end-systolic volume indexes (EDVI and ESVI), ejection fraction (EF) and stroke volume (SV) were calculated. Results Compared to patients without ME, those with ME present at CMR were older n (42.9+/-14.8 vs. 36.7+/-16.6, p = 0.145) and more frequently males(59.4% vs. 38.8%). At the same time, EF was significantly lower in patients with ME(50.9+/-14.5% in group 2 vs. 58.4+/-10.2% in group 1, p = 0.03). Patients from group 2 also exhibited a more pronounced dilatation of ventricular cavities, as reflected by a significant increase of ventricular volumes and especially of the ESVI(109.8+/-125.9 versus 80.1+/-14.2, p = 0.5 for EDVI, and 65.2+/-109.1 vs. 30.0+/-11.4, p = 0.02 for ESVI). Compared to the group without ME, those with ME presented a significantly lower stroke volume index: 44.2+/-17.3 in group 1 vs. 47.7+/-7.5, p = 0.03 in group 2. Conclusions In patients with COVID-19 myocarditis, presence of ME at CMR imaging is associated with a worse evolution of the left ventricular function, as reflected by increased ventricular dilatation and decreased cardiac output in the post-COVID period.

Assessment of Left Ventricular Myocardial Fibrosis in Adult Patients With Ebstein Anomaly: A Retrospective Cohort Study Based on Cardiac Magnetic Resonance and Histopathological Samples.

The association between Ebstein anomaly and myocardial fibrosis, particularly in the left ventricle, has been controversial. We aimed to assess the prevalence of replacement fibrosis with a focus on the left ventricle (LV) using cardiac magnetic resonance (CMR), make a histopathological association between LV fibrosis and CMR findings, and explore whether LV fibrosis is an independent risk factor for cardiovascular disease mortality using a derived risk score. We performed a 12-year (2009-2021) retrospective cohort of adult patients with Ebstein anomaly who underwent CMR. The CMR evaluation included a comprehensive assessment of myocardial fibrosis by late gadolinium enhancement (LGE). Four postmortem samples were obtained from our cohort and stained using Masson trichrome to characterize LV fibrosis. We used Cox-regression analysis to identify and derive a prediction score that associated LV fibrosis with cardiovascular disease mortality. We included 57 adults with Ebstein anomaly (52% men; median age, 29.52 [interquartile range, 21.24-39.17] years), of whom 12 died during follow-up. LGE prevalence by CMR was observed in 52.6% in any chamber; LV-LGE in 29.8%. Histopathological findings revealed a mid-wall pattern with predominantly interstitial fibrosis and minimal replacement fibrosis. LV-LGE was associated with increased risk of cardiovascular disease mortality (hazard ratio, 6.02 [95% CI, 1.22-19.91]) attributable to lateral and mid-wall LV segment involvement. Our mortality score achieved an overall good prediction capacity (R2, 0.435; C statistic, 0.93; Dxy, 0.86). There is a high prevalence of LV fibrosis replacement in adults with Ebstein anomaly, characterized by specific CMR and histological patterns. Furthermore, LV-LGE fibrosis is an independent predictor of cardiovascular disease mortality, which could be integrated into risk assessment in clinical management.

2D Strain Analysis in Myocarditis-Can We Be Any Closer to Diagnose the Acute Phase of the Disease?

The aim of present study was to assess left ventricular myocardial deformation detected by 2D STE in patients with suspected acute myocarditis (AM) early on admission in whom later cardiac magnetic resonance (CMR) evaluation was performed. A total of 47 patients with suspected AM based on clinical practice were prospectively enrolled. Coronary angiography was performed on all patients to rule out significant coronary artery disease. CMR confirmed myocardial inflammation, oedema, and regional necrosis meeting the Lake Louise criteria in 25 patients (53%, oedema (+) subgroup). In the remaining patients, only LGE was confirmed in the sub-epicardial or intramuscular localization (22 patients, 47%, oedema (-) subgroup). Early on admission, echocardiography with measurements of global and segmental longitudinal strains (GLS), circumferential strains (GCS) at the endocardial (endocardial GCS) and epicardial (epicardial GCS) layers, transmural GCS, and radial strains (RS) were performed. Mild reduction of GLS, GRS, and transmural GCS values were found in patients with oedema (+) subgroup. The epicardial GCS turned out to be the diagnostic factor for oedema with a cut-off point of 13,0% (AUC 0.747, p = 0.0005). Twenty-two patients (all but three) with an acute phase of myocarditis and epicardial GCS -13.0% or less had oedema confirmed by CMR. 2D STE can help to set the diagnosis of AM in patients with acute chest pain with a normal coronary angiogram. The epicardial GCS can serve as a diagnostic factor for oedema in patients with early stage of AM. In patients presenting with signs of AM (oedema in CMR), the epicardial GCS is modified in comparison with a subgroup without oedema; therefore, this parameter could be used to improve the performance of ultrasound.

Exploring the EVolution in PrognOstic CapabiLity of MUltisequence Cardiac MagneTIc ResOnance in PatieNts Affected by Takotsubo Cardiomyopathy Based on Machine Learning Analysis: Design and Rationale of the EVOLUTION Study.

Takotsubo cardiomyopathy (TTC) is a transient but severe acute myocardial dysfunction with a wide range of outcomes from favorable to life-threatening. The current risk stratification scores of TTC patients do not include cardiac magnetic resonance (CMR) parameters. To date, it is still unknown whether and how clinical, trans-thoracic echocardiography (TTE), and CMR data can be integrated to improve risk stratification. EVOLUTION (Exploring the eVolution in prognOstic capabiLity of mUlti-sequence cardiac magneTIc resOnance in patieNts affected by Takotsubo cardiomyopathy) is a multicenter, international registry of TTC patients who will undergo a clinical, TTE, and CMR evaluation. Clinical data including demographics, risk factors, comorbidities, laboratory values, ECG, and results from TTE and CMR analysis will be collected, and each patient will be followed-up for in-hospital and long-term outcomes. Clinical outcome measures during hospitalization will include cardiovascular death, pulmonary edema, arrhythmias, stroke, or transient ischemic attack.Clinical long-term outcome measures will include cardiovascular death, pulmonary edema, heart failure, arrhythmias, sudden cardiac death, and major adverse cardiac and cerebrovascular events defined as a composite endpoint of death from any cause, myocardial infarction, recurrence of TTC, transient ischemic attack, and stroke. We will develop a comprehensive clinical and imaging score that predicts TTC outcomes and test the value of machine learning models, incorporating clinical and imaging parameters to predict prognosis. The main goal of the study is to develop a comprehensive clinical and imaging score, that includes TTE and CMR data, in a large cohort of TTC patients for risk stratification and outcome prediction as a basis for possible changes in patient management.

Diagnostic and Prognostic Role of Cardiac Magnetic Resonance in MINOCA: Systematic Review and Meta-Analysis

BackgroundMyocardial infarction with nonobstructive coronary arteries (MINOCA) is common in current clinical practice. Cardiac magnetic resonance (CMR) plays an important role in its management and is increasingly recommended by all the current guidelines. However, the prognostic value of CMR in patients with MINOCA is still undetermined. ObjectivesThe purpose of this study was to determine the diagnostic and prognostic value of CMR in the management of patients with MINOCA. MethodsA systematic review was performed to identify studies reporting the results of CMR findings in patients with MINOCA. Random effects models were used to determine the prevalence of different disease entities: myocarditis, myocardial infarction (MI), or takotsubo syndrome. Pooled odds ratios (ORs) and 95% CIs were calculated to evaluate the prognostic value of CMR diagnosis in the subgroup of studies that reported clinical outcomes. ResultsA total of 26 studies comprising 3,624 patients were included. The mean age was 54.2 ± 5.3 years, and 56% were men. MINOCA was confirmed in only 22% (95% CI: 0.17-0.26) of the cases and 68% of patients with initial MINOCA were reclassified after the CMR assessment. The pooled prevalence of myocarditis was 31% (95% CI: 0.25-0.39), and takotsubo syndrome 10% (95% CI: 0.06-0.12). In a subgroup analysis of 5 studies (770 patients) that reported clinical outcomes, CMR diagnosis of confirmed MI was associated with an increased risk of major adverse cardiovascular events (pooled OR: 2.40; 95% CI: 1.60-3.59). ConclusionsIn patients with MINOCA, CMR has been demonstrated to add an important diagnostic and prognostic value, proving to be crucial for the diagnosis of this condition. Sixty-eight percent of patients with initial MINOCA were reclassified after the CMR evaluation. CMR-confirmed diagnosis of MINOCA was associated with an increased risk of major adverse cardiovascular events at follow-up.

CMR-based right ventricular strain analysis in cardiac amyloidosis and its potential as a supportive diagnostic feature.

Right ventricular (RV) strain has provided valuable prognostic information for patients with cardiac amyloidosis (CA). However, the extent to which RV strain and strain rate can differentiate CA is not yet clinically established. CA underdiagnosis delays treatment strategies and exacerbates patient prognosis. Evaluation of cardiac magnetic resonance (CMR) quantified RV global and regional strain of CA and HCM patients along with CA subtypes. CMR feature tracking attained longitudinal, radial and circumferential global and regional strain in 47 control subjects (CTRL), 43 CA-, 20 hypertrophic cardiomyopathy- (HCM) patients. CA patients were subdivided in 21 transthyretin-related amyloidosis (ATTR) and 20 acquired immunoglobulin light chain (AL) patients. Strain data and baseline clinical parameters were statistically analysed with respect to diagnostic performance and discriminatory power between the different clinical entities. Effective differentiation of CA from HCM patients was achieved utilizing global longitudinal (GLS: 16.5±3.9% vs. -21.3±6.7%, p=0.032), radial (GRS: 11.7±5.3% vs. 16.5±7.1%, p<0.001) and circumferential (GCS: -7.6±4.0% vs. -9.4±4.4%, p=0.015) right ventricular strain. Highest strain-based hypertrophic phenotype differentiation was attained using GRS (AUC=0.86). Binomial regression found right ventricular ejection fraction (RV-EF) (p=0.017) to be a significant predictor of CA-HCM differentiation. CA subtypes had comparable cardiac strains. CMR-derived RV global strains and various regional longitudinal strains provide discriminative radiological features for CA-HCM differentiation. However, in terms of feasibility, cine-derived RV-EF quantification may suffice for efficient differential diagnostic support.