Extracardiac Findings Research Articles

Clinically significant extra-cardiac findings in asymptomatic HIV-positive men undergoing cardiac magnetic resonance imaging.

Increased research-based imaging has led to an increase in clinically significant extra-cardiac findings. HIV patients are at increased risk of having polypathology at a younger age; therefore, it may be hypothesised that they would have more incidental findings on imaging. We reviewed the magnetic resonance imaging results of 169 HIV-positive and 40 HIV-negative, clinically well volunteers undergoing cardiac magnetic resonance imaging scanning to assess the prevalence of subclinical cardiac pathology. This sub-study assessed the prevalence of clinically significant extra-cardiac findings. Associated risk factors were assessed and clinical follow-up and outcome were ascertained. Of the HIV-positive study group, 12/169 (7.1%) vs. 1/40 (2.5%) control patients had a clinically significant extra-cardiac finding which warranted further radiological or clinical intervention (p = 0.28). A total of three out of 169 (1.1%) were highly clinically significant findings. On logistic regression analysis, age was the only significant contributing factor (p = 0.049); no HIV-associated factors were found to be significant. The prevalence of clinically significant extra-cardiac findings of 7.1% in this HIV-positive cohort is comparable to the prevalence found in previous studies carried out on an older, sicker general population. This highlights the need for planning for unexpected outcomes and also the high rate of clinically significant findings in a seemingly well HIV-positive population.

Current Role of Cardiac and Extra-Cardiac Pathologies in Clinically Indicated Cardiac Computed Tomography with Emphasis on Status Before Pulmonary Vein Isolation

The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI). 224 patients (64 ± 10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as "significant" if they were recommended to additional diagnostics or therapy, and otherwise as "non-significant". Additionally, cardiac findings were documented in detail. A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were "significant", and 423 (68 %) were "non-significant". In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the "significant" findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05). Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient.

Extracardiac Findings on Routine Echocardiographic Examinations

Incidental extracardiac findings (ECFs) have been described and studied in myocardial perfusion imaging, cardiac computed tomography, and cardiac magnetic resonance scanning. The literature is surprisingly limited with regard to ECFs in echocardiography. The aim of this study was to evaluate the prevalence and the clinical significance of ECFs in routine echocardiographic studies. The literature in other cardiovascular modalities was searched to identify and classify ECFs. ECFs in reports of transthoracic and transesophageal echocardiographic studies performed at Temple Health Network between 2009 and 2011 were sought. A sensitivity analysis was performed by reviewing the actual echocardiographic images for a subset of studies (n = 350) to determine the sensitivity and specificity of the results. The electronic medical records of patients with ECFs on echocardiography were then retrospectively reviewed, except for those with pleural effusions and descending aortic atheroma. A total of 41,067 echocardiographic studies performed between September 2008 and September 2011 (39,269 transthoracic and 1,798 transesophageal studies) were screened. Of these studies, 66.5% were performed in the inpatient setting and 33.5% in the outpatient setting. The prevalence of ECFs was 4.4% (1,797 findings) and was constant during the study years. Pleural effusion was the most common ECF on transthoracic echocardiography, while descending aortic atheroma was the most common ECF on transesophageal echocardiography. Detailed chart reviews were performed in all patients with ECFs, except those with pleural effusion and descending aortic atheroma (351 cases). ECFs on echocardiography led to new diagnoses and altered management in the majority of patients with vascular or liver findings. In this large consecutive series, ECFs on echocardiography were relatively uncommon and had variable clinical implications. The majority or ECFs are likely low-risk findings (pleural effusion, ascites, and hiatal hernia) and can be managed conservatively. "Higher risk" findings such as liver abnormalities, inferior vena cava filling defects, mediastinal masses, and descending aortic dilatation frequently lead to significant changes in clinical management. There is a need for uniform reporting, appropriate training, and the establishment of national guidelines for ECFs on echocardiography.

Extra cardiac findings in cardiovascular MR: Why cardiologists and radiologists should read together

To assess prevalence and significance of extra cardiac findings (ECF) in clinical routine cardiovascular magnetic resonance (CMR) studies reported by cardiologists alone versus cardiologist and radiologist working together. One-thousand-seventy-four consecutive patients presenting at our institution for CMR work-up of multiple cardiovascular disease entities were enrolled retrospectively in two groups (cardiologists reading alone vs. cardiologists and radiologist reading together). In 1,074 routine CMR studies a total of 357 ECF's were identified in 235 patients yielding a prevalence of 21.9 %. Of these 357 ECF's more than one-third were previously known. In the remaining 223 previously unknown findings 118 (52.9 %) were considered as major ECF's (92 patients), and 105 (47.1 %) were considered as minor ECF's (69 patients). Cardiologists reading alone reported 23 previously unknown ECF's in 23 patients, versus 200 previously unknown ECF in 138 patients by cardiologists and radiologists working together, p < 0.0001. Nevertheless, highly significant ECF's with major prognostic implications, such as the initial diagnosis of malignancy in an individual with no history of cancer, are extremely rare (n = 3, 0.3 %). Cardiologists alone, as well as cardiologists and radiologists working together seem to do well with reporting of such extremely important ECF's. The prevalence of all ECF's was 21.9 %, and 14.9 % of previously unknown ECF's, respectively. However, the prevalence of highly significant ECF's was low. Joint reading with cardiologists and radiologists may increase the number of ECF's detected in CMR studies, but it remains unclear if this could result in an improved long-term outcome of patients undergoing routine CMR.

Significant incidental findings in 9-year old children undergoing cardiovascular magnetic resonance imaging for research

Background The management of incidental findings in research imaging is a contentious issue. The imaging field of view in cardiovascular magnetic resonance imaging (CMR) studies often extends well beyond the cardiac anatomy, particularly on initial scout views. In clinical CMR there is limited data on incidental extra-cardiac findings in adults and even less in children. In research studies we are unaware of any data on incidental findings (cardiac or extra-cardiac) involving CMR of children. The aim of this study was to report on significant incidental findings noted in a research cohort of healthy children undergoing CMR. Methods

Detection Rate of Trisomy 21 in Fetuses with Isolated and Non-Isolated Aberrant Right Subclavian Artery

Objective: The purpose of this study was to determine the frequency of chromosomal anomalies among the fetuses with isolated and non-isolated aberrant right subclavian artery (ARSA), and to evaluate the sonographic findings associated with ARSA. Methods: This is a retrospective study conducted during the period between January 2008 and December 2012 at the maternal fetal medicine units of three different referral centers. Results: Among the 148 cases of ARSA, 98 were isolated and 50 were associated with cardiac anomalies, extracardiac malformations or soft markers. Trisomy 21 was the only chromosomal anomaly with a prevalence of 6.8% (10/148). The corresponding rate was 6.1% (6/98) and 8% (4/50) for isolated and non-isolated ARSA, respectively. Cardiac anomalies, extracardiac findings and soft markers were detected in 5.4% (8), 10.8% (16) and 24.3% (36) of cases, respectively. Among the 10 fetuses with trisomy 21, 6 were isolated, 4 were associated with soft markers, 2 were associated with fetal growth restriction and 1 was associated with hydrops fetalis. Cardiac anomalies were not observed in any of these fetuses. Conclusion: The prenatal diagnosis of ARSA should prompt meticulous anatomic survey, and karyotype analysis might be offered even in the absence of associated findings.

Prevalence of extracardiac findings in the evaluation of ischemic heart disease by multidetector computed tomography.

ObjectiveMultidector computed tomography (MDCT) is now commonly used for the evaluation of coronary artery disease. Because MDCT images include many non-cardiac organs and the patient population evaluated is highly susceptible to extracardiac diseases, this study was designed to evaluate the prevalence of extracardiac findings in the MDCT evaluation of ischemic heart disease.MethodsFrom March 2007 to March 2008, a total of six-hundred twenty patients, who underwent 64-slice MDCT evaluations for chest pain, or dyspnea, were enrolled in this study. Cardiac and non-cardiac findings were comprehensively evaluated by a radiologist.ResultsEnrolled patients included 306 men (49.4%), with a mean age of 66 years. Significant coronary artery stenosis was found in 41.6% of the patients. A total of 158 extracardiac findings were observed in 110 (17.7%) patients. Commonly involved extracardiac organs were lung (36.7%), hepatobiliary system (21.5%), thyroid (19.6%), kidney (10.8%), spine (9.7%) and breast (0.6%). Of those 110 patients, 50 (45.5%) patients underwent further diagnostic investigations. Malignant disease was detected in three (2.7%) patients (lung cancer, pancreatic cancer, and thyroid cancer).ConclusionsExtracardiac findings are frequently present and should be a concern in the MDCT evaluation of chest pain syndrome.

Malignant Incidental Extracardiac Findings on Cardiac CT: Systematic Review and Meta-Analysis

The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies. A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated. The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma. Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.

Cardiac MRI: Diagnostic Gain of an Additional Axial SSFP Chest Sequence for the Detection of Potentially Significant Extracardiac Findings in the Cardiac MRI Examination Setting

Cardiac MRI (CMRI) is an effective method for imaging of the heart. The aim of our study was to assess whether an axial chest sequence in addition to the standard CMR examination setting has advantages in the detection of potentially significant extracardiac findings (PSEF). 400 consecutive patients were imaged at 1.5 T for clinical reasons. In addition to the standard long and short-axis views, an axial SSFP sequence was obtained covering the thorax from the lung apex to the diaphragm. All sequences were separately evaluated for PSEF. A total of 25 PSEF were diagnosed in 400 patients, including 16 pleural effusions, a pulmonary fibrosis, a spondylodiscitis, ascites, lymphadenopathies, relapse of a mamma carcinoma, growth of adrenal glands metastases and diaphragmatic elevation. All 25 PSEF were detected by reading survey sequences. 24 of the 25 PSEF were detected by the additional SSFP chest sequence as well as the CINE sequences. In our study the additional axial SSFP chest sequence didn't show a benefit in the detection of PSEF. With the survey sequences we were able to detect all PSEF. We conclude that survey images should be assessed for additional findings.

Does CMR have an additive role over echo in evaluating ischemic LV dysfunction?

PurposeTo emphasis the role of cardiac magnetic resonance compared to echocardiography in evaluating patients with ischemic cardiomyopathy to accurately assess global and regional Left ventricular function which is essential for prognosis and for evaluating therapeutic responses. Methods and materialsThe studied group included 37 patients already diagnosed as having ischemic cardiomyopathy. All patients were subjected to full history taking and radiological evaluation using a 1.5-T MR system and echocardiography. Comparison was made between echocardiography and cardiac magnetic resonance regarding segmental wall motion by using the 17-segment model of the American Heart Association. Agreement regarding segmental wall motion was assessed by using Cohen’s Kappa statistics. Also ejection fraction measurement by both modalities was compared. Detection of transmural extent of myocardial scar was also performed. ResultsPoor agreement between cardiac magnetic resonance and echocardiography regarding segmental wall motion with Cohen’s Kappa is 0.195, P value of <0.001. Mean ejection fraction by cardiac magnetic resonance was 33.3% and mean ejection fraction by echocardiography was 29% with a mean difference of 4.3%. ConclusionCardiac magnetic resonance is superior to echo in evaluating segmental wall motion abnormality with echo underestimating segmental wall motion abnormality yet nearly similar ejection fraction values by both modalities were achieved. Moreover, cardiac magnetic resonance is better in evaluating associated cardiac abnormalities as well as extracardiac findings due to its higher spatial resolution. In addition, cardiac magnetic resonance is used in myocardial viability assessment in the same setting which if combined with segmental wall motion abnormality can lend a hand in evaluating the cardiac contractile reserve.

18F-FDG PET/CT diagnosis of unexpected extracardiac septic embolisms in patients with suspected cardiac endocarditis

Acute infective endocarditis is a potentially life-threatening disease. Its outcome strongly depends on systemic embolization and extracardiac infections. When present, these conditions usually lead to a more aggressive therapeutic approach. However, the diagnosis of peripheral septic embolism is very challenging. (18)F-Fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT has proven to be accurate for the detection of inflammatory diseases and occult infections. The aim of this study was to assess the added value of (18)F-FDG PET/CT in the detection of extracardiac embolisms in the evaluation of patients with suspected valvular endocarditis (VE). Seventy-one patients with suspected infective endocarditis, enrolled between June 2010 and December 2012, underwent (18)F-FDG PET/CT with the standard procedure on a dedicated PET/CT scanner. Extracardiac findings were subsequently evaluated with other imaging procedures. Of the 71 patients with suspicion of infective endocarditis, we found unexpected extracardiac findings in 17 patients (24%) without any clinical suspicion. Extracardiac findings were subsequently evaluated with other imaging procedures. PET/CT detected unexpected extra sites of infection in 24% of cases, leading to changes in therapeutic management in a very relevant percentage of patients. These findings may have important therapeutic implications.

1026Incidence and influence of extra-cardiac findings in clinical CMR

1026Incidence and influence of extra-cardiac findings in clinical CMR

Prevalence and clinical relevance of extra-cardiac findings at cardiac magnetic resonance imaging

Ziele: The aim of this study was to assess the incidence of extra-cardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart including surrounding structures and to determine the influence of those findings on patient's management. Methode: N = 854 patient studies (median age 58 ± 12 years, male 63%) were included and examined by 1.5 Tesla (T) MR to primarily analyze the cardiac anatomy and secondly the surrounding structures. Extra-cardiac findings were classified as significant (Group A) if they were recommended to additional diagnostics or therapeutical interventions and as non-significant if there was no influence on patient's management (Group B). Ergebnis: 631 patient studies were free of any kind of extra-cardiac pathologies. In the remaining cases, 286 extra-cardiac findings were examined. There were –0.33 extra-cardiac findings per patient. 49 were defined as significant (Group A) and 237 as non-significant findings (Group B). The most common Group A findings were suspicious pulmonary nodules or masses > 4 mm diameter (n = 14) and aortic aneurysms (n = 5). In Group B, most of the findings were hepatic cysts or hemangiomas (n = 50), followed by renal cysts (n = 47). 8 malignancies were certainly observed. The most frequent indication for CMRI was evaluation of cardiac stress ischemia (n = 501, 59%). Schlussfolgerung: Extra-cardiac findings in clinical CMRI are common in patients referred to CMRI (26%). Radiologists and cardiologists have to be aware of relevant extra-cardiac findings which might require additional diagnostics or treatment. There is an importance of paying appropriate attention to structures outside of the heart.

Prevalence and clinical relevance of extracardiac findings at cardiac MRI

To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management. During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B). The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management. Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.

Combined non-invasive functional and anatomical diagnostic work-up in clinical practice: the magnetic resonance and computed tomography in suspected coronary artery disease (MARCC) study

The combined use of cardiac computed tomography (CT) coronary angiography (CTCA) and myocardial perfusion imaging allows the non-invasive evaluation of coronary morphology and function. Cardiovascular magnetic resonance (CMR) imaging has several advantages: it can simultaneously assess myocardial perfusion, ventricular and valvular function, cardiomyopathy, and aortic disease and does not involve any additional ionizing radiation. We investigated the combined use of cardiac CT and CMR for the diagnostic evaluation of patients with suspected coronary artery disease (CAD) in clinical practice. A total of 192 patients with low or intermediate pre-test probability of CAD underwent CTCA and CMR. All patients with obstructive CAD on CTCA and/or myocardial ischaemia on CMR were referred for invasive coronary angiography (ICA). Fractional flow reserve was measured in case of intermediate lesions (30-70% diameter stenosis) on ICA. Additional cardiac and extra-cardiac findings by CTCA and CMR were registered. The combination of CTCA and CMR significantly improved specificity and overall accuracy (94 and 91%) for the detection of significant CAD compared with their use as a single technique (CTCA 39 and 57%, P < 0.0001; CMR 82 and 83%, P = 0.016). No events were recorded during follow-up (18 ± 6 months) in 104 patients who did not undergo ICA. Furthermore, the combined strategy provided an alternative diagnosis in 19 patients. The combined use of CTCA and CMR significantly improved specificity and overall diagnostic accuracy for the detection of significant CAD and allowed the detection of alternative (extra-)cardiac disease in patients without significant CAD.

OP-149 CORONARY ARTERY FISTULAS IN IRAQI ADULT PATIENTS

Results: 177 extracardiac findings have been found at 80 (42.1%) cases. It was found that there were minor findings at 40 (20%) of the cases and there were major findings at 40 (20%) of the cases. We found that at 13 (6.8%) cases there were a total of 13 highly significant findings containing aortic aneurysm, pulmonary mass, pulmonary nodules, infiltrates, pneumonectomy, adrenal nodular thickening and liver mass lesions. Conclusion: Because extracardiac structures such as lungs, mediastinum and upper abdomen are being appropriate for evaluating with coronary calcium scoring with multidetector computed tomography and extracardiac findings are frequent, the radiologist who has been reporting these findings should be aware of the likelihood, frequency and importance of these findings.

Accurate localization of incidental findings on the computed tomography attenuation correction image

This observer performance study assessed lesion detection in the computed tomography attenuation correction image, as would be produced for myocardial perfusion imaging over a tube current (mA) range. A static anthropomorphic chest phantom containing simulated pulmonary lesions was scanned using the four available mA values (1, 1.5, 2 and 2.5) on a GE Infinia Hawkeye 4. All other computed tomography acquisition parameters remained constant throughout. Twenty-seven cases showing zero to four lesions were produced for a free-response receiver-operating characteristic method. Image observations were completed using our novel web-based ROCView software under controlled conditions. The Jackknife alternative free-response receiver-operating characteristic (JAFROC) figure of merit was used for significance testing, wherein a difference in lesion detection performance was considered significant at P values less than 0.05. Twenty readers with varying computed tomography experience (0-24 years) evaluated 108 images using an ordinal scale to score confidence. The JAFROC analysis showed that there was no statistically significant difference in performance between mA values (P=0.439) for this sample of observers. In conclusion, no significant difference in lesion detection performance was seen between the mA values. This suggests that there is no value in using anything other than the lowest mA value for the investigation of incidental extracardiac findings.

Prevalence and clinical relevance of extra-cardiac findings at cardiac magnetic resonance imaging

Background The aim of this study was to assess the incidence of extra-cardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart including surrounding structures and to determine the influence of those findings on patient’s management. Methods N=854 patient studies (median age 58 ± 12 years, male 63%) were included and examined by 1.5 Tesla (T) MR to primarily analyze the cardiac anatomy and secondly the surrounding structures. Extra-cardiac findings were classified as significant (Group A) if they were recommended to additional diagnostics or therapeutical interventions and as non-significant if there was no influence on patient’s management (Group B). Results 631 patient studies were free of any kind of extra-cardiac pathologies. In the remaining cases, 286 extra-cardiac findings were examined. There were ~0.33 extracardiac findings per patient. 49 were defined as significant (Group A) and 237 as nonsignificant findings (Group B). The most common Group A findings were suspicious pulmonary nodules or masses > 4 mm diameter (n=14) and aortic aneurysms (n=5). In Group B, most of the findings were hepatic cysts or hemangiomas (n=50), followed by renal cysts (n=47). 8 malignancies were certainly observed. The most frequent indication for CMRI was evaluation of cardiac stress ischemia (n=501, 59%). Conclusions Extra-cardiac findings in clinical CMRI are common in patients referred to CMRI (26%). Radiologists and cardiologists have to be aware of relevant extra-cardiac findings which might require additional diagnostics or treatment. There is an importance of paying appropriate attention to structures outside of the heart.

Perinatal outcomes and anomalies associated with fetal right aortic arch

To evaluate the prenatal findings, associated anomalies, and prognosis of right aortic arch (RAA) anomalies. All cases referred for detailed ultrasonography and fetal echocardiography between October 2006 and July 2009 were systematically examined for aortic arch anomalies and associated cardiac and extracardiac anomalies. Prenatal findings of all cases with aortic arch anomalies and intracardiac and extracardiac findings were prospectively registered in an electronic database that included fetal echocardiography. Outcomes of the cases were collected postnatally from the patients' obstetricians, neonatal unit archieves, and pediatric cardiologists. We detected 12 cases of RAA (0.37%; n=12/3200). Mean gestational age at diagnosis was 24 weeks (range, 21-33 weeks). Of the 12 cases of RAA, five (41.7%) had a major cardiac defect, including tetralogy of Fallot (n= 3), atrioventricular septal defect (n=1), and ventricular septal defect (n=1). An extracardiac anomaly was observed in three cases (25%). The fetal karyotype was trisomy 21 in one case with increased nuchal translucency (6.6 mm). Microdeletion 22q11 analyses performed in three cases were normal. The postnatal courses of the cases with isolated RAA were uneventful. Two cases associated with major cardiac and extracardiac anomalies were lost in the early neonatal period. The case of trisomy 21 was terminated. The other four cases of RAA with an associated cardiac anomaly are currently in follow up. Aortic arch anomalies, particularly RAA, can be diagnosed by fetal echocardiography. The prognosis for isolated RAA is relatively good compared with that for RAA with associated anomalies.

134 MRI Detection and Quantitative T2 Measurement of Cardiac Involvement in Systemic Sarcoidosis: Initial Results

Cardiac involvement (CI) in patients with systemic sarcoidosis is a major risk factor for sudden cardiac death. The incidence of CI on autopsy can be up to 40% although it is only observed in 5-10% patients diagnosed clinically with systemic sarcoidosis. Early detection of CI may therefore potentially alter prognosis and treatment options. In this study, we investigated the prevalence of CI in a cohort of biopsy proven sarcoid patients using quantitative cardiac MRI techniques of late-gadolinium-enhancement (LGE) and T2 mapping. 28 patients with systemic sarcoidosis, but without overt cardiac involvement [17 males (60%), ages of 50±10 years] had undergone an MRI study on a 1.5T magnet system. Pre-contrast MRI included left ventricular (LV) and right ventricular (RV) function and quantitative T2 measurements using T2 maps derived from a Multi-echo fast-spin-echo sequence (MEFSE) or T2 preparation spiral scan. Post-contrast LGE-MRI included inversion recovery fast-gradient-echo (IR-FGRE) and multi-contrast late-enhancement (MCLE) imaging. CMR42 was used for ventricular function measurement, LGE determination and quantitative T2 calculation. LV functional parameters in 28 patients were normal while the RV function was decreased (mean LVEF: 61.2±8.5%; mean RVEF 48.0±6.6%). 21.4% of subjects (6/28) had CI showing patchy or multiple focal hyper-enhancement patterns in LV free wall, papillary muscles (PM) or inter-ventricular septum. In two cases with PM involvement, the PM abnormal LGE foci were only observed on MCLE. The LV systolic function was preserved in patients with CI (n=6, LVEF=59.4±12.1%). For pre-contrast T2 measurements at the mid-LV level, there was no significant difference in T2 averaged over the myocardium between LGE negative (n=22) and positive group (n=6) (LGE negative vs. positive: 53.0±2.6 ms vs.53.4±2.4 ms, p=0.76). However, a significant decrease in T2 was observed in LGE-positive regions, compared to the LGE negative group (focal LGE-positive regions vs. negative: 40.0±2.4 ms vs. 53.0±2.6 ms, p<0.0001). Extra-cardiac MRI findings were documented in 63.4% of patients, primarily hilar and mediastinal lymph node enlargement. In three LGE-positive patients, follow-up MRI at 15-26 months demonstrated LGE foci were stable in 2 subjects whilst one subject demonstrated new transmural LGE. LGE-MRI especially MCLE method can detect cardiac involvement in sarcoidosis. In focal areas of LGE, there is a decrease in T2. This may be secondary to asteroid bodies containing calcified proteins - suggesting chronic stable disease. Changes in T2 might therefore reflect different phases of cardiac sarcoid, thus providing a non-invasive method for monitoring disease and therapy.